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E ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> -TO-E-"-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f' � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedb e <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. I., <br /> :30B ADDRESS/LOCATION ZS eola_ CENSUS TRACT .� <br /> 'Owner's Namel v E,10 Phone <br /> Address �," Z City77 <br /> k Contractor's Name P License #.2e'9575P Phone ' W <br /> TYPE OF WORK (Check) : NEW WELL '/a DEEPEN/ / RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION I PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> { <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ICV SEWER LINES PIT PRIVY <br /> "SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE° PRIVATE DOMESTIC WELL dl� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation /61 <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal D - <br /> Cathodic Protection; _ Rotary Type of Grout <br /> ,Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: QG.G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V .S H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP "REPAIR: / / State Work Done <br /> pES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure '' . <br /> I hereby agree to/ omply.with all laws and regulations of the San Joaquin Local-�Health District <br /> and the State of^California pertaining to or'"regulating well 'coiistruction. 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 twell and notify- them before putting the .well in use. The above <br /> information is true the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI I NS CT IO . <br /> SIGNED TITLE <br /> (DRA L T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY, DATE INSPECTION BY ( DATE <br /> E H. 1426 Rev. 1-741Z1` .3/76 2M <br /> 14.6 <br />