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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> yi <br /> F0 '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 3r17$--Z3 � <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 /> f _ <br /> JOB ADDRESS/LOCATION J , " vq CENSUS TRACT <br /> Owner's Name — �J Phone4t�� <br /> Address IJIl IV i dCl'1/1 City ' <br /> it <br /> Contractor's Name d-� 'J / ____ License d "3�-�IPhone 41 aha <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR IV PUMP REPLACEMENT <br /> Other J // <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY "1 <br /> k 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,'.REPAIR: -S tate_Work.Done - - _ - -- -T- - <br /> pES4RUCTION 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 <br /> information is true to the�best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE u1n_.Ar [iae.•,.l.1 _- <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> F OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II PE ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />