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li P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,;OFFI.CE USE: :'1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuecOA 16 MI <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 :Wade 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 <br /> r r 1 -t- 5aN 1I CENSUS TRACT <br /> Owner's Name LCs r r'/ A)>%_ fjn I Phone . T <br /> Address I Yo 8 45-;rF I ctl <br /> t j 1 Cit ° <br /> Contractor's Name Yi License Phone?VY-13 4/7 <br /> TYPE_OF WORK-. (Check)t NEW WELL /�EEPEN ' RECONDITION' -T DESTRUCTION /-7 <br /> PUMP INSTALLATION /� PUMP REPAIR /PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C,1: <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 /> __,fi==­Vomestic/private L Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing !.7. r� <br /> 1 <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection II �-'Rotary Type of Grout SL .ti <br /> Disposal YOther Other Informati n <br /> Geophysical , Surface Seal Installed 'B : <br /> PUMP INSTAL <br />� CATION. Contractor 7q v,% <br /> Type 'of Pump tJ A.P. <br /> i <br /> G <br /> PUMP REPLACEMENT f/ ' .State Work Done' , <br /> PUMP ,REPAIR: I'State Waxk Dane : -� - - <br /> DES�� TRiICTON 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 -tell and notify them before putting. the..well in.use.... .The above <br /> k informati,oln 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPART T USE ONLY <br /> PHASE I .1 <br />` APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS81III NAL INSPECTI N <br />� INSPECTION BY DATE INSPECTION BY DATE <br /> h/7 5 2M-- <br /> E ii 1426 Rev. 1-74 :� - �� <br />