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�'� l• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH,OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> R� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 76 <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 Rules and Regulations of the San Joaquin Local Health--,District, <br /> JOB ADDRESS/LOCATION . V4- k1 �, Sv4t, CENSUS TRACT <br /> Owner°s Name G ore , -r Phone <br /> Address s2Q , ogcCity <br /> Contractor's Name Aft / License #dIZ&CPhone 444J,7476 <br /> TYPE OF WORK (Check): NEW WELL /—T DEEPEN '/'7 RECONDITION /-' DESTRUCTION f7 <br /> PUMP INSTALLATION /!PUMP REPAIR Y/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Off, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITC OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other Other Information <br /> Geophysical J Surface Seal Installed BY: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. G O <br /> r.. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> ES;TRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction.- Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well in use.. The above f <br /> information is true to the-best of my knowle ge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FIKAL UNSPEOrT04- <br /> SIGNED TITLE �r <br /> (DRA PLOT PLAN ON j9VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION <br /> INSPECTION <br /> INSPECTION BY BATE INSPE T <br /> E <br /> S <br /> Rev. I-74 <br /> H 1426- [� ; <br />