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S <br /> ` k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: <br /> G 3.601 E. Hazelton Ade. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued_�:­' o--71 <br /> (Complete In Triplicate) <br /> Application lis 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. <br /> JOB ADDRESS ALOCATION CENSUS TRACT ' <br /> Owner's Name Phone <br /> f <br /> Address 5a"ecL&AVtA� Rd._ FrVJVU',P4_ <br /> City <br /> Contractor's! Name License ijPhone �l ��� <br /> F <br /> TYPE OF WORK� (Check) : NEW WELL / / DEEPEN / / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / - PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /DD PIT PRIVY <br /> SEWAGE DISP AL FIELD CESSPOOL/SEEPAGE PIT OTHER W : <br /> 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 /> Domestc/private PDri=l.led Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 3' <br /> Irrigatp <br /> ion Gravel Pack Depth of Grout Seal <br /> i <br /> Cathodic Protection /kotary Type of Grout <br /> Disposal Other Other Information <br /> Geo�h�jsica Surface Seal Installed By: <br /> P INSTALLATION• Contractor <br /> Type of Pump v H.P. <br /> P MP <br /> —R EMENT: / / State Work Done <br /> PUMP '.REPAIR;,, / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate.Depth <br /> Describe Material, and -Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 /> 3RIOR TO GRO6,TING AND A FINAL INSPECTION, <br /> SIGNED IItl , <br /> J. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDZ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ,ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE II /FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/ f-- DATE 9"`�/-Z� <br /> i <br /> s�77 2M <br />_, H 1426 � Rev. . 1-74 _ _ <br />