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, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE_ OFFICE ?7� /1i, 601 E. Hazelton Ave. , Stockton, Calif. �G <br /> Telephone: (209) 466-6781 c <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/-`M,/` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue d/-/L'7 <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 -' ` � � __. � cczw. CENSUS TRACT <br /> Owner's Name <br /> hf ) kms_ Phone <br /> Address ( e� � .LCity <br /> Contractor's Name looff/ _ ty. •.P. �Ae, C,,, License Phone <br /> TYPE OF WORK (Check) : -NEW WELL _/r/ DEEPEN `/ `/ RECONDITION r' DES1`RUCTION /'� <br /> PUMP INSTALLATION / / PUMP ;REPAIR / _/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Lan, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C9. CESSPOOL/SEEPAGE PIT 1 Q¢' OTHER <br /> PROPERTY LINE/a'PRIVATE DOMESTIC WELL ---O-- 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 L <br /> Domestic/public Driven Gauge of Casing z4e> I9r <br /> Irrigation _ Gravel Pack Depth of Grout Seal ,,? <br /> Cathodic Protection _ Rotary Type of Grout e- 47A.,.A7— V <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ t <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 />'RIOR TO GROUTING AND A FINAL SPECTION. <br /> SIGNED TITLE ®_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��'l DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL ANSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE ; <br /> d <br /> b/77 2M <br /> E H 1426 Rev. - I-74 <br />