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SAN-JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. cL-Te7� <br /> THIS PERMIT EXPIRES 1 YEARPRpM DATE ISSUED Date Issued g 71,1- <br /> (Complete In Triplicate) <br /> r Application is hereby made to the 'San Joaquin Local. Health District for a permit to construct <br /> f 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 4 G G �./ CENSUS TRACT <br /> Owner's Name l Phone <br /> Address l b(c L� A/ T>,t1s_C City <br /> �C �� <br /> Contractor's Name License # tone {�-z..746 7•� <br /> .II � <br /> TYPE OF WORK (Check): , NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /? <br /> r PUMP INSTALLATION I I PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER, LINES' PIT PRIVY <br /> SEWAGE DISPOSAL TMD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL d <br /> INTENDED .USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/ rivatei <br /> _� p 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 ,i Other Other Information <br /> Geophysical a Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. ✓ <br /> PUMP REPLACEMENT: / State Work Done _ ,cdQ �VL <br /> PUHP*REPAIR: /� State Work Done _ <br /> k <br /> ®ES TRUCTION OF WELL: Pell Diameter + Approximate Depth <br /> Mescribe 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 myi�vork on a new we11, ,T will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RESORT of the well and notify them before putting the..well in.use. The above <br /> :information is true to �the•best-of- m rnowle ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ', ' PRIOR TO GROUT NG AND A FINAL INSPECT <br /> SIGNED �i E ���. ... <br /> k 0 __(4RAWjPLbT PLAN ON REV SE SID <br /> f 3 �, F R PART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B �I DATES <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PUA19E <br /> 11ZOINAL INSPECTION <br /> + INSPECTION BY DATE INSPECTION DATE -/ 7 <br /> " } E H 1426 Rev. 1-74 1-74 Q3 <br />