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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOk 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 Issueo <br /> (Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local HealthDistrictfor a,p.ermit 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name I JV N, Phone _ <br /> Address <br /> _ City . ,�o Dj_(34_) <br /> Contractor's Name ) �. .,�►-- - License #,,2)9, 010 Phone 0 <br /> TYPEOFOF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR j / 'PUMP REPLACEMENT— <br /> S-0 <br /> EPLACEMENT <br /> Other <br /> - � y 'y$ �.�'-_.a•��j,. t�. # 1.x..4 � . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE#A'GE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ..._" , !PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />'i Domestic/p.r,iateY -- - Drilled---- -- �,ia:wof-�6deld� asng <br /> Domestic/,public � {` D.r_.ven' , Gauge of Casing •;'' <br /> Irrigation draave]_-'" 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 �N <br /> Type of Pump H.P. ! <br /> \,A --- <br /> PUMP REPLACEMENT: State Work Done t s.!`L <br /> r PUMP .REPAIR: /% State Work Done <br /> DES-TRLTCTION OF WELL: Well Diameter � �'�-� <br /> .,g Approximate Depth <br /> Describe Material and Procedure _ ''j i <br /> I hereby agree to comply with al]- 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 <br /> .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•-b.est'of my 'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR0 INC AND' ' ` IN L'.. INSPECTION.i, ,. <br /> TITLE <br /> '* _.`(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BYE' "': _ <br /> ADDITIONAL COMMENTS: <br /> PHASE Iz 4ROUT INSPECTION P SE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. . 1-74 �s�7.7 2M <br />