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p C G 5AN'JJOAQUIN LOCAL HEALTH DISTRICT <br /> F0_R_,' SPF" ' USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '.j­w� V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?S=QTY-' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 OL 1I ,,c c� le M,16 .41' 14.... 2,,Z CENSUS TRACT <br /> Owner's Name ' Phone / <br /> Address 1 It f A/ A tU,a)-e City <br /> Contractor's Name .t)r License # / ?y.(" -Phone L 7d 7 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION /7/--PUMP REPAIR /� PUMP REPLACEMENT /? <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 /> Domestic/private Drilled Dia. 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: Contractorr �°'' <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :lid /X7 State Work Done - ,� ". <br /> RES•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 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 2ELUTING AND A FINAL INSPECTIOM. J ; <br /> SIGNEDITLE <br /> W PLOT PLAN ON RWERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY/:];� DAT Z2 r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT <br /> TJOA <br /> 17;1 � <br /> INSPECTION BY cJ DATE -7- 7- '7 INSPECTION BY - j DA <br /> E H 1426 Rev. 1-74 1-74 2 <br />