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' SAN JOAQUIN'LOCAL HEALTH. DISTRICT <br /> 6;F-OEOFFICE USE: 1 1 E Hazelton Ave Stockton, Calif. <br /> . <br /> t 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 'L42 <br /> 27 <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. 1862 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION ,�F.dam �. �'. f] .� T CENSUS TRACT ' <br /> w Owner's Name /LC -�C �� Phone 3 - <br /> Address 0 City f S <br /> Contractor's Name, License #16.4.V3 Phone 3 6 J <br /> TYPE OF WORK (Check) : NEW WELL/ / ---DEEPEN/ / RECONDITION [—/ DESTRUCTION /_7 <br /> TAL <br /> k PUMP INSLATION REPAIR 4W—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 /> K 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 RotaryType of Grout <br /> Disposal t Other• Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:------ -Contractor----- <br /> Type of Pump _ '�' H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: State,Work- Done ,Lc� - ge_ <br /> i <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best f my know1 d a and 'beli.ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND,6 FIN PECTION <br /> SIGNED TITLE <br /> jLrC-LDRAW.:MT PLAN ON REVERSE SIDE) n j` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f a DATE ' <br /> ADDITIONAL COMMENTS: <br /> } PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> . H 142b /762M <br /> E <br /> t-__ Rev. 1-74 <br />