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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE USE: 1601 E. Hazelton Ave.:, Stockton, Calif. 7�_ <br /> Telephone: (209) 466-6781 <br /> 3,V APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No - 3 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 54 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1/7 <br /> JOB ADDRESS/LOCATION 2, CENSUS TRACT, <br /> Owner's Name % T � - � Phone -3d, -,,'4- 7 <br /> Address _ t, --x ,> Cit <br /> Contractor's Name �, License V.-, t7 hone 7W_312 4_ <br /> TYPE OF WORK (Check): NEW WELL/DEEPEN /_7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR 1_7 PUMP REPLACEMENT /r <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> i;Dndustrial able Tool Dia. of Well Excavation _ X. <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I/ <br /> Irrigation Gravel Pack Depth of Grout Sealey ` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done "_rf <br /> a <br /> 1 <br /> PUMP .REPAIR: /7 State Work Done <br /> ,RES,mRUCTION OF WELL: Well Diameter Appro imate Depth z e_ <br /> Describe Material and Procedureh <br /> I hereby agree to comply with all laws andegulations 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 GROU NG ANDAFINAL INSPECT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ( .e DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL I-NSPECTIWPPN <br /> INSPECTION BY DATE INSPECTION BY DATE /v <br /> E H 1426 Rev. 1-74 1-74 2M <br />