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4r <br /> SAN JOAQUIN L0ML-HEALTH DISTRICT <br /> FOIA OFFICE USE: 1601 E. 'Hazelton Ave. ,, Stockton, Calif. <br /> Telephone : (209.) 466-=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />" (Complete In Triplicate) <br /> f 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 /> r <br /> JOB ADDRESS/LOCATION ./ t e e 6 g CENSUS TRACT ' <br /> Owner's Name Zese z '-r, b Phone 9fe <br /> Address 3_�' ' �� Ma ids ,s f % Cit S <br /> 57/�/lY 7� -- - <br /> Contractor's Name Q Vele License �Z Phone ZZI <br /> TYPE OF WORK (Check) : NEW WELL /A�' DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUXP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> W <br /> x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f +` PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD 1& CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY, LINE/61' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation �►Z�' <br /> [,— Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ /Q <br /> Irrigation Gravel Pack Depth of Grout Seal Sly" <br /> Cathodic Protection _� Rotary Type of. Grout _ _�� �.✓% _ . <br /> Disposal Other Other Information <br /> Geophysical, Surface Seal Installed By: <br /> ' PUMP INSTALLATION: Contractor <br /> } <br /> Type oftPump - H.P. ' <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: We11 Diameter f 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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T'0 'GROUTING AND A` FINAL INSPECTION. <br /> SIGNED TITLE <br /> - (DRAW PLOT -PLAN- ON REVERSE--SIDE)•- ' <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY { TDATE �{ ! <br /> '• ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> f INSPECTION BY ( Ajj <br /> DATE INSPECTION BY — 11111�9 DATE <br /> /7 2M <br /> E H 1426 Rev. , 1-74 *�-- <br />