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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF-0r--­OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. , C` <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10 !9f '7 <br /> 1 (Complete In Triplicate) <br /> Application i 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/LOCATION i M�� /� F ���.ve rc Ir , Aeor, S6 P7e,A*.4cr 0CENSUS TRACT <br /> Owner's Name CAM-efl-lt & ,e e!5. Phoneef/--,4/.-- <br /> Address _ / -/ S-,6-- --—�.�,a: City <br /> Contractor's Name ��, e 17 fidWe"-'� �,7n� �� License �� �L Phone W- <br /> 77--�--,-- <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jM�_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> A--- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ��pe;r'/ ` 8�, � �� dX l^�, r. <br /> Type of Pump _'Y a�2/i fl —r-r—T H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work 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 /> 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 /> SIGNED ..,� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ��Z DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> E H 1426 Rev. - I-74 <br /> of 77 2M <br />