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SAN JOAQUIN LO&� "ttf;ALTH DISTRICT <br /> -fOF OFFICE USE: 1601 E. Hazelton Ave. ,` Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 17 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-5' <br /> �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 in <br /> Local Health District. <br /> JOB ADDRESS/ F�,0441M�- � e <br /> 0?/ CENSUS TRACT <br /> Owner's NameQ^/��jlrJ� Phone <br /> Address - -- JLLi`% oO7 City <br /> Contractor's Name 0 Yn ,s License #407" -00 <br /> e,� �� <br />• i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN/ / RECONDITION / / DESTRUCTION /� <br /> PUMP INST ATION / I PUMP REPAIR I I PUMP REPLACEMENT /_7 <br /> Other /_7 7` <br /> DISTANCE TO NEAREST: SEPTIC TANK. - SEWER LINES IT PRIVY i <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT�Qd �9THER <br /> PROPERTY LINE �RIVATE DOMESTIC WELL + PUBLIC DOMESTIC WELL C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,h Lkn - <br /> Domestic/public Driven Gauge of Casing 72_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout /9 ,ZL z <br /> Disposal Other Other Information �. <br /> i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> IPUMP REPLACEMENT:" /'/ State Work Done <br /> PUMP .REPAIR: / / StateWork Done <br /> DESTRUCTION 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 /> j 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 INSPECTIO <br /> SIGNED TITLE A(11� / <br /> P T L N REVERSE SIDE) <br /> FOR,. DEqRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE .-�—�l <br /> ADDITIONAL COMMENT : <br /> PHA 99T INSPECTION PHAKI;VFI)(AL INSPECTIONINSPECTION BYefif- �, DATE - TNSPE TION BY - DATE <br /> 7F 3/ 6 <br /> E H 1426 Rev. 1. 74 "` <br />