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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,.-:�-'z� 0 <br /> (Complete In Triplicate) 7" <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 (712-2-� CENSUS TRACT <br /> Owner's Name �A fIJK Soi- A k j Phone ,3/ `Z0-41 ,',,--- <br /> �. U A L A l d2J <br /> Address � � � 2 City S MrT TV 14 <br /> 1 <br /> Contractor's Name OA� YY ,L( _ U�Q /_L/(� ense #7�Phone 2.,3'r�Q', <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 3> <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> __ omestic/private Drillad Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -'d <br /> Cathodic Protection fotary Type of Grout Eow <br /> Me <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 <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 AND A INAL INSPECTION. <br /> SIGNED _ _ _.. - - <br /> TITLE <br /> DRAW PLOT ;PIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ap <br /> APPLICATION ACCEPTED BY /�,[ DATE Z <br /> ADDITIONAL COMMENTS: _ <br /> P I GROUT INSPECTION PIJA$F, II/UlAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -, DATE (\-NLk-16 <br /> E H 1426 Rev. 1-74 1177 2M <br />