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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR?'OFFICE USE: V ' 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.fir/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued La- �-J <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 /> JOB ADDRESS/LOCATION Lac.-St~�.£ Lr ��R �. h�c'� 4&- e&��TCENSUS TRACT <br /> Owner r s Name Z u- Phone �3 C k-Z 21 (� <br /> city -Z�� <br /> Address . <br />' Contractor'a Name _ (�} y*—p Licensed 2373 Phone <br /> V Lc d i <br /> TYPE OF WORK--(C1,eck):`'NEW-WELI.-T7 DEEPEN 17 RECONDITION/7 `:DESTRUCTION--f- <br /> PUMP INSTALLATION / J PUMP REPAIR )5;�PUMP REPLACEMENT /7 C? <br /> Other /-7 <br /> .� <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : PIT PRIVY ^1 <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` t- Dia.-.of-Well'-Casing <br /> + iDomestic/public Driven Gauge of- Casing o <br /> Irrigation Gravel Pack 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 Com .- <br /> Type of Pump v v H.P. <br /> Y ' <br /> PUMP REPLACEMENT: / / State Work Done ►- <br /> PUMP '.REPAIR: State Work Done E,LL iZZ -W"( <br /> L <br /> } <br /> &ES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 t ue to the•best of my-knowledge and belief I WILL CALL FOR-A 'GROUT INSPECTION <br /> PRIOR TO GROUT AND A FINSPECTION. <br /> SIGNED TITLE <br /> a_DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II IN ECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M �.; <br />