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SAWJOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;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 Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t 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 /> I� JOB ADDRESS/LOCATION LU I a V e t. 1 S\'ktJjCENSUS TRACT <br /> Owner's Name ' a N C-a: i 4S%V-n\ Phone y -cl 4, <br /> Address 6S N C - `.iaV 4 i_:, A, City <br /> Contractor's Name I 6 Ivy `? I�� C ., License # . . . . . . Phone L' <br /> TYPE OF WORK (Check): NEW WELL Xr DEEPEN '/7 RECONDITION /_7' DESTRUCTION / Y� <br /> PUMP ;INSS ALLATION / PUMP REPAIR/ ;/ PUMP REPLACEMENT <br /> Other.'/. % <br /> y <br /> DISTANCE TO NEAREST: SEPTIC ,TANK 1.11 SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL ' LD CESSPOOL/SEEPAGE PIT OTHER <br /> 90Y <br /> PROPERTY LINERIVATE. DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL * , CONSTRUCTION SPECIFIC TIONS ' <br /> Industrial J Cable-Tool Dia. of Well Excavation <br /> Domestic/private" j Drilled P Dia', of Well Casing <br /> Domestic/public. 1 Driven Gauge,/nf Casing <br /> Irrigation' i Gravel Pack Depth of GroutSeal 0\ <br /> Cathodic Protection � am <br /> _ Rotary Type of Grout Gti <br /> t r { <br /> Disposal i Other Other Information ' <br /> ,Geophysical _ -. \ <br /> Surface Seal Installdd�By: <br /> PUMP INSTALLATION: Contractor <br /> Tyre .of Pump H.P. v <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP :REPAIR: _/ t/_7State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter roximate Depth <br /> Describe Material and Procedure F <br /> I hereby agree to comply withlallclaws. and regugLations 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.the..well. 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 &VIRL, INSP ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE �r- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> IAPPLICATION' ACCEPTED BY <br /> DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE M14FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74 rr 1./tee <br />