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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 /> andor 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 /> JOBADDRESS/LOCATION IF- a 9P4.) <br /> CEN <br /> SUS TRACT <br /> OwnJr'a Na ^ <br /> '� `� °" ' • �c Phone <br /> Address <br /> City <br /> I <br /> t <br /> Cont actor' Name 1y $ <br /> A4 F ren n_�, �.� License # 2±Lf Phone 5`4'f- 3 9 S'/ <br /> TYPE OF WORK (Check) : NEW WELL 17 DEEPEN '/7 RECONDITION / DESTRUCTION /_ ! <br /> PUMP INSTALLATION PUMP REPAIR '/-7—PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE EYNESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> �h Domestic/public Driven Gauge of Casing <br /> !j Irrigation �Y Gravel Pack Depth of Grout Seal <br /> E1 Cathodic Pr_otec_tion Rotary Type of Grout <br /> 91 Disposal Other Other Information ' ' i <br /> U Ed <br /> Geophysical Surface Seal Installed By: <br /> PUMP1INSTALLATION: Contractor ti S <br /> Type of Pump ';kr� H.P. _y6 <br /> PUMP� REPLACEMENT: . <br /> State Work Done <br /> PUMP!'REPAIR: / / State Work Done <br /> DESTR! <br /> UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . . . . <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 i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELLI�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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> . ' <br /> APPLI;CATION' ACCEPTED BY DATE y - 17 -7� 1 <br /> ADDITIONAL COMMENTS: azL�_ — <br /> IN PHASE II GROUT INSPECTION PHAS I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> i <br /> E H 1426 Rpv_ '1..74 <br />