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i <br /> SAN JOAQtjIN LOCAL HEALTH DISTRICT <br /> FOET50 CE USE: 1601 E. Hazelton Ave;';' Stockton, Calif, <br /> Telephone: ..(20) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1l'YEAR-'FROM DATE ISSUED Date Issued�T <br /> (Complete Triplicate) <br /> Apoiieation is hereby made to the San Joaquin Lbcal 'Health District for a permit to construct <br /> and/or install the work herein- described. This`Applieation is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulation6.of.the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION 5 CENSUS TRACT , <br /> Owner°s Name i�teyl VgR�QO�� _ _ _ Phone �,q - O'R,12 - - <br /> _,Addtesa.;. City <br /> Contractor's NamerS�o vp License _ /17.24/ Phone <br /> a� ey ,. <br /> TYPE OF WORK (Check): NEW WELL fN DEEPEN '/-T RECONDITION- /-T DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR I� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7A CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL AQ. PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,of Well Excavation _ 2 <br /> k — Domestic/private Drilled Dia. :of Well Casing 91 _-- <br /> Domestic/public., Driven Gauge of Casing In a w \ <br /> Irrigation Gravel Pack Depth of Grout Seal S5 <br /> Cathodic Protection Rotary Type ,of Grout <br /> -Disposal ' Other Other Iiiforiaati.on <br /> Geophysical Surface Seal Installed BY: <br /> Is1400T We.{� <br /> PUMP INSTALLATION: Contractor <br /> ���]ti ,n. <br /> Type of Pump S'Ua M H.P. <br /> e 4 1 <br /> s <br /> PUMP REPLACEMENT: / / State Work. Done ' <br /> PUMP:REPAIR":'' "!J^"""" /-7-State-Worse Done _.. . <br /> pES�TRUCTION OF WELL: Well Diameter,"` Approximate Depth <br /> Describe Material and Procedure <br /> } <br /> I hereby agree to comply withiall 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 mg 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-besi of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOG ING ANRIA FINAL INSPECTION.. <br /> SIGNED TITLE <br /> r + -(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> F <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/Fla& INSPECTIO <br /> INSPECTION BY DATE � INSPECTION BY f DATE <br /> 6 . <br /> E'H-1426 Rev. 1-74 1-74 2M <br />