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SAN 'JOAQUIN LOCAL HLALTH�DISTRICT + <br /> LFOF- �O�F�FI�CaUS�E: 1601 E. Hazelton Ave. , 'StoCkton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No. 40 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-ol 7� <br /> (Complete In Triplicate) <br /> APplicition 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 E <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health Distract. ! <br /> I . <br />' JOB ADDRESS/LOCATION <br /> CENSUS TRACT j <br />' Owner's Name <br /> l ev r Phone 4 ; -7-1 <br /> Address <br /> City r �' <br /> Contractor's Name 00a" .4/Z &--4 License # B Phone <br /> i <br /> TYPE OF WORK (Check) : NEW,WELL,.J[-f__DEEPEN :_/.../F. .RECONDITION.-/�_./ ._DESTRUCTION /� &_ <br /> PUMP INSTALLATION /44 PtW REPAIR <br /> / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /def SEWER LINES job'./- 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 t-, Cable Tool Dia. of Well Excavation <br /> L Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public, Driven Gauge of Casing - - <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary Type of Grout y <br /> Disposal Other <br /> Geophysical Other information <br /> R. <br /> Surface Seal Installed By .e <br /> PUMP INSTALLATION: Contractor , <br /> Illie <br /> Type of Pump _ <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / J State Work ,Done % <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 rioilfy�'them before putting the well in use'. The above <br /> information is true to the best of myknowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING ANkA FINAL INSPECTION. �• * a' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ 1 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY /y►,�.�- DATE <br /> ADDITIONAL COMMENTS: <br /> �`- '-PHASIMI GROUT INSPECTION <br /> PHASE IIIf�INAL INSPECTION'' <br /> INSPECTION BY � � DATE �/" INSPECTION BY DATE &l - <br /> 2 2 <br /> E H 1426 Rev_ 1-7L 1 .177 Ou <br />