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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFI�'E USE: A ' ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. (/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �d �-Sj�3 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued,~ Wy <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` �'" lc�� �, CENSUS TRACT <br /> Sk <br /> Owner's Name ei( y Phoie <br /> Address City fel <br /> Contractor's Name ;,;i'e ,• / f,7, .,i/j,S• License PhoneV ' -'Fr <br /> TYPE OF WORK (Check) : NEW WELL NIT DEEPEN / / RECONDITION / / DESTRUCTION /-T _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - -_ SEWER, LINES jam•_ PIT PRIVY -e = <br /> SEWAGE DISPOSAL FIELD ..__ CESSPOOL/SEEPAGE PIT OTHER- -r <br /> PROPERTY LINE_��'PRIVATE DOMESTIC "� , - . <br /> WELL - PUBLIC DOMESTIC WELI <br /> INTENDED USE 'TYPE OF WELI _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> /p �_ Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �/ � PSI ' P**%- <br /> Irrigation jf Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �„ /s.� ,t r': sr, r:`.. <br /> s .. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ;` 7 -- 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 <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 /> �- <br /> AV (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7_ <br /> E H 1426 Rev. , 1-74 <br /> 6/77 , <br />