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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> t J APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 74,33 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application i 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 Ruleand Regulations of the San Joaquin Local Health District. <br /> 0111911--UIT 'et, <br /> JOB ADDRESS/LOCATION a ;n,� ,► , r CENSUS TRACT ! <br /> Owner's Name ,g,�,G,,�/'; /�y-p�f' Phone <br /> i <br /> Address C ;Z-3 City <br /> Contractor's Name '- License #,ej!_ ''Phone 7. 26,7,E <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /X/ 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ��n 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 V " 'a <br /> Type of PumpT H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> zt <br /> PUMP . : b(/ State Work Done .Z / A/ �- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure p` <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 INSPE <br /> SIGNEDI2�1TLE <br /> (DRAW PL PLValEV SE <br /> AN ON RSIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E,1 DATE `� 1;77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY DATE / w`" 77" <br /> E H 1426 Rev. 1-74 <br /> 117.7 _ � 2M <br />