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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, i <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 7/�,7 <br /> (Complete In Triplicate) j <br /> Application is hereby .made to the San Joaquin Local Health District for a permit to construct j <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 /> .TOB ADDRESS/LOCATION 44 411 -C CENSUS TRACT <br /> Owner s>Name �. eJ71 - Phone <br /> 7 ,G' C City <br /> Address <br /> Contractor's Name 1,.I_)?l.V License #2 4s74 I Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / 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 <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 /> F - Cathodic Protection Rotary Type of Grout <br /> i Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor fi <br /> Type of Pump S vA, H.P. <br /> PUMP REPLACEMENT: / State Work Done /��/S/� / ice• re/ <br /> T <br /> PUMP .REPAIR: / / State Work Done - <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 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 thewell in use. The above <br /> information 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 P 'T PLAN 'ON REVERSE SIDE i " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE _/ '7. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE FY-L3- <br /> 3/7 <br /> - 3- <br /> E H`1426 Rev. 1-74 <br />