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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$ OFFICE USE: ' i1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 485-5781 <br /> VPLICATYON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> N <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ­3-7,$ <br /> k (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. i <br /> If; 5 X13 DCS h a1 Zz7-,0,3 0 -0� <br /> JOB ADDRESS/LOCATION '� � CENSUS TRACT <br /> 1 <br /> II Owner°s Name Phone <br /> Address '- �" R� City <br /> i� 8w 54� <br /> Contractor's Name License its 1ffLg. Phone i- <br />� w <br /> 4 � I <br /> ,_.. r - ... qH ... ,.. -.�-=.fir--•+^- .. L - �..,�'r �-��. <br /> TYPE OF WORK (Check): p EW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 t , <br /> `PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES -A PIT PRIVY <br /> SEWAGE DISPOSIELD "., —,—.CESSPOOL/SEEPAGE PIT OTHER <br /> s FROPERTY'`LINE -- PRIVATE• DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE',OF WELL .CONSTRUCTION SPECIFICATIONS <br /> IndustriaCable Tool Dia, of Well Excavation <br /> Domestic/pr'ivate :Dri-filed f Dia. of Well Casing ,l ' loll <br /> r <br /> Domestic/public" Drive�-' Gauge of Casing /� <br /> - °irrigation= = � -Gravel Pack ,—Depth of.-.Grout Seal 6 <br /> Cathodic Protections Rotary ' , Type of Grout" <br /> Disposal',, � ! Other ; Other ,Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Conti-kc-tor' <br /> �. Type of Pump lk _ H.P. <br /> PUMP REPLACEMENT; / / State Work.Done <br /> PUMP .REPAIR: '/� State Work�Done t <br /> �ESTRUCTION OF WELL: Well MDiameter f� s Approximate Depth / <br /> " Describe Material and�_.ft9cedure� <br /> I hereby agree to comply with all la6s 'anVJegulations ,of the San ,Joaquin Local Health District <br /> 1 and the State of "California pertaining,. or egulat.ing.well construction. Within FIFTEEN DAYS <br /> after completion of myi�work on a new well, Y 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 trke toll the,best"of" my knowledge and belief.. I WILL CALL FOR "GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE-•SIDE - <br /> _FOR-DEPARTMENT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �� j PiA I FT NSPECT N, <br /> INSPECTION BY DATE. DTE <br /> i. E H 1426 Rev. 74 %' 1-74 2M <br />