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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE, VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�1 3 r2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2--y_7�4- i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San JoaquinI <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3 <br /> JOB ADDRESS/LOCATION 2 S9, ENSUS TRACT { <br /> 1 <br /> Owner q s Name ��l�Y�y ��?/fd�rJ .f1 d��? > Phone 5/- <br /> fi - <br /> Address Q City ' <br /> Contractor's Name �Q License # 1:291)3 Phone 5-222=zo- � <br /> - . <br /> C <br /> TYPE OF WORK (Check): NEW WELL IFI DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION %/ PUMP REPAIR 1_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /A0 SEWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CEL/SEEPAGE PIT OTHER <br /> i <br /> F PROPERTY LINE - PRIVATE DOMESTIC 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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of,Grout Seal ..4 <br /> Cathodic Protection ✓ Rotary Type of Grout n. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1�UMP IiEPATR: <br /> /7 State Work-,k-Dane <br /> _ <br /> ES;TRUCTION OF WELL: Well 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 G OUTING FINAL I PECCT 0 . <br /> SIGNEDtaealf <br /> TITLE <br /> (DROV PLOT I E SID-Etr <br /> FOR DEPARTMENT US ONLY <br /> PHASE I / ji <br /> APPLICATION ACCEPTED BY /� �/ DATE <br /> ADDITIONAL COMMENTS: •_ - ._,_._„__.._ <br /> P4ASFk24I GROUT INSPECTIONPHAS I FINAL INSPECTION <br /> INSPECTION .BY DATE `` INSPECTION BY DATE !Z-/o - cl <br /> 1 E H 1426 Rev. 1-74 <br /> 1-742M- <br />