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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PFOE"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> L 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,5/7-7� <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 Joaquii <br /> County Ordinance No, 1862 and the Rules and- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZSR° �il/w, CENSUS TRACT <br /> 3 Owner's Name <br /> _ Phone <br /> Address �+ <br /> V . . .� City Lk A' .G <br /> Contractor's Name Selz � <br /> yv ov License #o�_79B ip Phone 939v2267 <br /> TYPE OF WORK (Check) : NEW WELL�/ / DEEPEN%/ RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP. INSTALLATION / / PUMP REPAIR `/ / PUMP REPLACEMENT N <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER 9 <br /> PROPERTY LINE '- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 3 <br /> INTENDED USE -TYPE OF WELL --._ C <br /> _ CONSTRUCTION SPECIFICATIONS <br /> 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 CP1 <br /> Cathodic Protection Rotary Type of Grout ° <br /> Disposal Other Other Information _ <br /> Geophysical , }., Surface Seal Insrtalled B <br /> PUMP INSTALLATION: Contractor <br /> _ —.T _. . -r.".. - - <br /> Type of Pump H.P. <br /> f PUMP REPLACEMENT: State Work Done -2rn a <br /> 5. <br /> PUMP .REPAIR: .tm� - -• .�_,�. _ <br /> State Work Done <br /> DESTRUCTION OF WELL We11/Diameter <br /> �- Approximate Depth <br /> __D e s c r ib e-Ma t ex i a7land Procedure <br /> j <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 comple,tion,. of my,-work on a new well, _T+will furnish the-San Joaquin Local Health District a <br /> WELL DRILLERS REPORT..of the welland notify them before putting. the. well in use The above <br /> informaeion,is 'true to 'the' 6eest` of'my knowledge and belief. I'WILL CALL FO A GROUT INSPECTION <br />` PRIOR T-0,GROU G._AN A FI L -I SPECTION.. , -^1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I /FIN INSPECTIO <br /> INSPECTION BY .DAfiE:'�f' INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 n/77 - ! <br />