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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. �%/- S63� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 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 /> JOB ADDRESS/LOCATION AI A-4 CENSUS TRACT <br /> Owner's Name 3 , Q h n Phone <br /> Address Cj D .3 a h�4 J eC C/1 G City '-�C4��4r D <br /> Contractor's Name C License #�J- "phone ! <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR IX-7-pump REPLACEMENT 1-7 <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing w <br /> Domestic/public Driven Gauge of Casing d <br /> X 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: Ll State Work Done <br /> PUMP :REPAIR: /k? State Work Done <br /> PE_S-TRU`CTION 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 o my knowled$e belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I -T—. <br /> SIGNEDTLE <br /> D T LAN ON REMsE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEy <br /> ADDITIONAL COMMENTS: 2,Z1 <br /> PHASE II GROUT INSPECTION PHASE III/FZNAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' E H 1426 Rev. 1-74 <br /> 1-74 <br />