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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED : Dat Issued 21 <br /> M <br /> " fid n/ G�r4- (Complete In Triplicate)' ' <br /> Application is iereb madd� the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is wade in compliance- with Salt Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the- San Joaquin Local Health-District. <br /> JOB ADDRESS/LOCATION QJ "-c 5 t, aj <br /> tg„ _ .�. CENSUS .TRACT pis -rte- / <br /> ,' <br /> �/ <br /> Owner's Name -fl OA,4.j,�, 03— Phone <br /> Address . City !� .. . .. <br /> Contractor's Name _ of �], fyylL License # Phone Ll 69 3 - <br /> TYPE OF WORK-(Check) : NEW WELL 17 DEEPEN 17 RECONDITION /-7 DESTRUCTION i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT; /7 ^�I <br /> Other /% I� i <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 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 it <br /> Cathodic Protection Rotary Type of Grout •10 <br /> Disposal Other Other Information it <br /> Geophysical Surface Seal Installed By 11 . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump it H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .PUMP-:REPAI•R.- -.--- - -,L7--State Work Done ,- <br /> ,2ES;TRUCTION OF WELL: Well Diameter proximate Depth <br /> Describe Material and Procedur 1 <br /> I hereby agree to comply with all laws and reguiat ons of tfflan Joaquin LocaV 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 LocallHealth. District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in user. The above <br /> information is true to the-beat of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO ING ANDA #jNAL INSP CTION. <br /> SIGNED TITLE <br /> R <br /> (DRAW PLOT PLAN ON REVERSE SIDE 'il: <br /> FOR DEPARTMENT USE ONLY I� <br /> PRASE I <br /> APPLICATION ACCEPTED BY� DATE <br /> ADDITIONAL COMMENTS. IM <br /> PHASE Il GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - Z- <br /> �� <br /> 31 E H 1426 Rev. 1-74 1-7G•• r� <br />