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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK-';5_FFI_nN USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-/S 6S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �� <br /> (Complete In Triplicate) '��,(dp.e 1 0*d7 jp�cn/, �' �,-_/-7� <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 :z C> ``' `7 - `� �y n < _ CENSUS TRACT <br /> Owner's Name ���/ �,�, �2tcad� Phone 7,C? <br /> Address :?e,> 4f,V4f City 4 .l <br /> Contractor's Name fp ;� ,,,,� � / � License Phone ^ <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN%/ RECONDITION /~/ DESTRUCTION /VT _ <br /> PUMP INSTALLATION / / PUMP REPAIR f / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK gip/ SEWER LINES f&l / PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD ✓'` / CESSPOOL/SEEPAGE PIT _ OTHER _ <br /> PROPERTY LINE)¢ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL f. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (�N . <br /> Industrial Cable Tool Dia, of Well Excavation <br /> -t-• Domestic/private - X Drilled Dia. of Well Casing %' a� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal "o t <br /> Cathodic Protection --r Rotary Type of Grout <br /> Disposal Other Other Information U <br /> Geophysical, Surface Seal Installed B : . ;, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - _ P - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <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 SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 'A <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA�T <br /> E H 1426 Rev. - 1-74 <br /> 6/77 2M <br />