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I <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> FOR,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 <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 RulesandRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c1g,' U, CENSUS TRACT <br /> Owner Q s Name t2 Fe Ruc 7 Phone �?3 — c;.?`W/ <br /> Address 4 , <br /> city ._, �eAty <br /> A <br /> Contractor's Dame =, _ '�,,) - License #Arm O 0 Phone ���.7 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_ RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION L-7 PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other f_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <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: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done �>R H'1 Mile j 76� o ,�,,, SA, Z(_-5 r <br /> PUMP :REPAIR: �/T7 State Work Done <br /> j&S 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 GRORTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R' DEPARTMENT USE ONLY <br /> PHASE I X?, <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />