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SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FOR MFICE 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 6 -IS-7(l <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 Joaquit <br /> County Ordinance No..,1862 and the Ilk and Re ulations of the San Joaquin Local Health District. <br /> b` {j�[ror toad tri Do„ F1.�� <br /> JOB ADDRESS/LOCATION Q ,3 _i ® U CENSUS TRACT <br /> Owner Is Name C 42 C V I-P, Phone <br /> Address City <br /> C Contractor's Name T hT t Iv x- D �L. kvi r>3 D <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL/?ALDEEPEN '/7 RECONDITION /? DESTRUCTION,7f <br /> PUMP INSTALLATION / / PUMP REPAIR /-7PUMP REPLACEMENT /_7 Other -- <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -PIT PRIVY e, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> + 1PROPERTY LINE -'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> C INTENDED USE ' TYPE OF WELL- - r- CONSTRUCTION SPECIFICATIONS <br /> Industrial ''. Cable Tool Dia, of Well Excavation �v <br /> Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/public Driven Gauge of Casing`, fl\ <br /> k Irrigation r Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout' Nk ] <br /> Disposal Other _ Other Information Ilk 1,. <br /> Geophysical Surface Seal Installed'`$ : <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP '.REPAIR: <br /> 1-7 State Work Dane <br /> E&TRUCTION OF WELL: Well Diameter r{ <br /> . Approxima a Depth <br /> Des ribe Mat tial and Prrocedure r <br /> T ra 7_ e t,✓a W Psi <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 FORA GROUT INSPECTION <br /> PRIOR TO/jR_OU_TjNc AND A FINAL-MNSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PFOR DEPARTMENT USE ONLY <br /> HASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ix FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION By,./ <br /> DATE <br /> 1 ' EH1 <br /> 426 Rev. Z-74 <br /> I_7I_7A Im <br />