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_ SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7( -//C7p <br /> Of Telephone: (209) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> AP <br /> 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 ljo. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G/S�(a CENSUS TRACT <br /> Owner's Name /YI!K l r C A L !3 6'5 Phone <br /> Address _ l !Z k 7 &' Ml/1/CP City <br /> Contractor's Name 1f License #_V = v Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /X-7 DEEPEN/_/ RECONDITION /-T DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION _Y/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1." 1 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 /> jw Ir- <br /> Domestic/private Drilled Dia. of Well Casing li-0- f© v\ <br /> Domestic/public Driven Gauge of Casing /0 <br /> Irrigation Gravel Pack Depth of Grout Seal $70 <br /> Cathodic Protection Rotary Type of Grout C � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �h ,z,�� 7-65-741 <br /> Type of Pump H.P. Z <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 AND A FINAL INSPECTION. <br /> SIGNED /� ? TITLE _,:,:a <br /> J� <br /> -jDM PLOrPLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1111s-1-741001 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/FI AL INSPECTIO <br /> INSPECTION BY DATE ; „� - y' INSPECTION BY DATE lIZ117 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />