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} O SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F0P OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27- <br /> THIS <br /> 7-THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1.862 antd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LQ �Ir /�. ,[.�-u.�,�CENSUS TRACT <br /> Owner'-s Name V Phone 3( F1 J �^-1 <br /> - <br /> Address 7 3 City <br /> Contractor's Name License AV2,323 Phone 3 �- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMPJNSTALLATION / / PUMP REPAIR/ / PUN? REPLACEMENT <br /> Other I / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -. 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 i. Surface Seal Installed By: <br /> PUMP INSTALLATION. -""``Contractor � -^-(l= - <br /> Type'; of. Pump H-.P. / <br /> PUMP REPLACEMENT: 4A;T-- State Work"ti6ne P,ct- �, �,� �2 ,LT�` •- <br /> PUMP .REPAIR: / / I, State Work Done a <br /> DESTRUCTION 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 regulatingwell-construction. Within FIFTEEN DAYS <br /> after completion of my worklon a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thelwell and notify them before putting the.-well in use. The above <br /> informatio s true to a best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TI FINAL NSPECTION. �J <br /> SIGNED TITLE - <br /> RAW, PLT PLAN 'ON REVERSE SIDE -r-_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,, DATE s"r J 7"7�? <br /> j` <br /> E H 1426 Rev. 1-74 376 .2M <br />