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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1�44 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b--2o-1y <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 _a6)_21 cX CENSUS TRACT <br /> Owner's Name Phone <br /> S 7 e Lp <br /> Address / <br /> city C-44-,o A,, <br /> Contractor's Name Q,� License (o(,gs Phone _6 ' I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7" <br /> PUMP INSTALLATION /�MP REPAIR / / PUMP REPLACEMENT /_ <br /> Other, / <br /> L <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELDA�rjX , CESSPOOL/SEEPAGE PIT OTHER �----7 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'—^ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4n, <br /> Industrial Cable Tool Dia. of Well Excavation /! <br /> D estic/private Drilled, Dia. of Well Casing <br /> Domestic/public Driven 1 Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Se (j <br /> Cathodic Protection i:�otary Type of Grout ', <br /> Disposal Other Other Information p 0 <br /> Geophysical Surface Seal Installed B 6A-C.• <br /> PUMP INSTALLATION: Contractor ! _ P A-C , (h <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <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 the. well in use. The above <br /> inf11ation is true to he b of- my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR on <br /> AND F S CTIO <br /> SIG TITLE (�7a gg0kr <br /> (DRAW PLOT LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE �7 D <br /> ADDITIONAL COMMENTS: <br /> PHASk GRO.T 1NSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY/(j DATE 7 INSPECTION BY W DATE 7 ; <br /> - '6 7 <br /> E H 1426 Rev. 1-74 ` l�� 7 2M <br />