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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. --� <br /> Telephone : (209) 466--6781 F„ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 7-jl,.7r0 <br /> THIS PERMIT EXPIRES ,I 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 /> � to es%' S:,f3r <br /> JOB ADDRESS/LOCATION _ -, � CENSUS TRACT <br /> Owner's Name zr ,i,,,�, Phone _ f f <br /> Address j73 d City GCS <br /> Contractor's Name 3 LIZ 1441 License #_� Phone F (- s y y <br /> _ i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR UMP REPLACEMENT <br /> Other / / <br /> — — <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 u <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ <br /> Domestic/private Drilled Dia. of Well Casing { � <br /> Domestic/public Driven Gauge of Casing `U <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 <br /> H.P. <br /> PUMP REPLACEMENT: / / 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 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 AN INAL INSPECTION. <br /> SIGNED <br /> TITLE sc:, J= n Cu. <br /> (D PLOT PLAN ON REVERSE SIDE) =,!:'n 'vtur C61 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I L i€, .:. ;,:, ; • ra <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2m <br />