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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SCANNED <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued IJ- S-7,Y-� <br /> (Complete In Triplicate) <br /> Application: is hereby made to the Salt 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 CENSUS TRACT <br /> Owner's Name �_ Phone <br /> Address /c�a.�Jr�.is o. City <br /> Contractor's Name License #1&071Phone 166el <br /> TYPE OF WORK (Check) : NEW WELL /,DEEPEN _7 RECONDITION /_7 DESTRUCTION /_7 ._ <br /> PUMP INSTALLATION PUMP REPAIR/ I PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY <br /> u SEWAGE DISPO.AL FIELD CESSPOOL/SEEPAGE PIT 174� 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 /> 1��^ Domestic/private Drilled bia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 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 <br /> Type of Pump ;► ' H.P. -,WNW i <br /> �s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /_7 State Work Done _ <br /> ES-TRUCTION 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 fe well and notify them before putting the-.well in use.. The above <br /> information is tri o t e-best,ofE. my knowle and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROIJ "F`l L�TNSi;f 4 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON 'REVE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PH E II AAOU7 INSPECTION PHASB_jII/FjeXALINSPECTIQN <br /> INSPECTION BY � DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />