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T� <br /> C 0h 4 JmoLGaC SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FORt OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - w Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1a,Y-;�," <br /> i (Complete In Triplicate) 201- r5•0-O� <br /> Application is hereby made tojthe 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.141862 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> ' .SD ZS �. -�.JW <br /> 30B ADDRESS/LOCATION CENSUS TRACT f <br /> t <br /> Owner's Name l�ag d r> e) Phone <br /> Address City <br /> Contractor's Name License # /Id 7;..J'Thone C14>-79 2 , { <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_ i <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other / / d <br /> Q1 <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER_"LINES PIT PRIVY <br /> -� sSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT +.. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL rb <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> -Domestic/privateDrilled Dia. of Well 'Casing— <br /> ' <br /> Domestic/public Driven Gauge of Casing <br /> �C. Irrigation Gravel Pack Depth of Grout Seal <br /> _E.. .--Cathodic Protection Rotary Type of Grout .,.....�,�. <br /> f Disposal Other Other Information <br /> I Geophysical r " Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumH.P. 7,4— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done <br /> MSTRUCTION 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 F'IF'TEEN 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 welland notify them before putting. the. well in-use.. The above <br /> information is true •tow the-best�,of my-knowledge- and be ief, .-'I."'WILL'"CALL °POR 'A"GROUt INSPECTION <br /> PRIOR TO GR AND A FINAL INSPECTIQ 3 <br /> SIGNED <br /> LE <br /> (DRAW P 0 PLAN ON REV SE SIDE) � <br /> DEPARTMENT USE ONLY s <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE /�V <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE IU/FIRAL IU/FIRANSPEC ION <br /> INSPECTION BY DATE INSPECTION- BY DATE 2, hL <br /> k E H 1426 Rev. 1-74 1-74 2M <br />