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/S JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> II 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 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. 1 <br /> 86� and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION - j .04 .h, CENSUS TRACT F <br /> Owner's Name JOY d y A/4.®�2 Phone <br /> Address City)F,r4R'J�19► C?�_ <br /> Contractor's Name ? License #345-728 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /_%_ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /10 PIT PRIVY L&�2 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL..119 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too! Dia, of Well Excavation 16)/z <br /> Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing I2 <br /> Irrigation Gravel Pack Depth of Grout Seal 5.0 <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ _ yLjE,c2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / Y State Work Done <br /> PUMP .REPAIR: /111'/ State Work Done <br /> DESTRUCTION OF WELL: We 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR I AN A FfNAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ONREVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY . . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION "PHASE III/FINAL INSPECTION <br /> INSPECTION BY 11 DATE d 77 <br /> INSPECTION BY DATE 7-/.- 77 <br /> E H 1426 Rev. 1-74 <br /> I s 1 f7 2M <br /> Z <br />