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V SAN JOAQUIN LOCAL .HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "0 a / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r <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 �� ,/� 7CC1= j — CENSUS TRACT <br /> Owner's Name Phone <br /> AddressC AIX- 7/;;el e City , <br /> Contractor's Name ft. ,y License Phone <br /> TYPE OF WORK (Check) : NEW WELL /;?- DEEPEN/_/ RECONDITION /7 DESTRUCTION /_7AL <br /> PUMP INSTLATION /I�,( PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK e O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE PIT /©a OTHER <br /> PROPERTY LINE/ PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL��_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrials Cable Tool Dia. of Well Excavation /!l , <br /> Domestic/private Drilled Dia. of Well Casing Gr T— <br /> �_ Domestic/public Driven Gauge of Casing L ' <br /> Irrigation Gravel Pack Depth of Grout Seal -3,0 Cathodic Protection Protection >;� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: -^{<7 <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump _ SU6s� �v�,�-i� y H.P. <br /> _ i. <br /> PUMP REPLACEMENT: j / 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 trict <br /> and the State of California pertaining to or regulating well'construction. Within FIFT9EN 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 w5"d notify them before putting the .well_in use. The above <br /> information is true to cthvJa,6st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND <br /> SIGNED TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e/`.' DATE 6 /o <br /> ADDITIONAL COMMENTS4,11s Ute <br /> PHAaFjVX GROUT INOECTION P S /FINALINSPE ION X18 <br /> INSPECTION BY DATE - ���g INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1 �7 <br />