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SAN JOA UIN LOCAL Q HEALTH DISTRICT <br /> 0% 0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -A <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.' � it <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued K-r-,l J <br /> (Complete In Triplicate) -- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct , <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Pules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name L l�q Ph <br /> one r _-6-AP, <br /> _ <br /> Address City <br /> i <br /> Contractor's Name /� "r_ (SL License4 Phone <br /> TYPE OF WORK (Check):] NEW WELL /77 --DEEPEN `/- -RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: ; SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` PROPERTY ,LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USEi TYPE OF WELL CONSTRUCTION SPECIFICATIONSi <br /> Industrial w Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' : <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f <br /> 8 � � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type-of 'Grt\ 1 1. + . <br /> Disposals -, ! Other Other` Information' <br /> Geophysical Y ` Surface Seal Installed By: <br /> PUMP INSTAd.'LATION: � Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'REPAiR: i /% State Work Done <br /> ESTRUMON OF'WELL: Well Diameter l� Approximate Depth ►7, <br /> i { Describe-Mdfffj&j -and'-Procedure <br /> I hereby agreed to comply with all lgws and regulations- of the. San Joaquin Local Health District ry <br /> and the State°of California pertaining. to or-regulat.l1ng -,sell constrIuction. Wit�IJ,jv FIFTEEN DAYS <br /> after completion of my work on a new wello _will- furbish °the San Joaquin. La69 Health District a <br /> �Jsr <br /> WELL DRILLERS RE RT of ..the wel aid notify them befo e,putting. the,,, � in.use.. The above <br /> informat n rue to the. tr f. knowled-ge--and-belief: ,;i L��CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NG A F CTIO + 'fiii5si" <br /> SIGNED.°.. xa.t. l;iiy;l}I}y TITLE <br /> (D QTI� LAN ON REVERSE SIDE <br /> ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,yj/ DATE <br /> ADDITIONAL COMMENTS: . y <br /> PHASE II GROUT INSPECTION ` 1 PHASE I FINAL INSPECT ON <br /> INSPECTION BY DATE } d � INSP9CtION BY DATE _ <br /> f , <br /> ! E.H 1426 Rev. 1-74 <br />