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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE•,0 ICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Dt�yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7-!d 7S <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ^isg /, Milo sn Arr,4 GZf CENSUS TRACT <br /> Owner's Name -- Phone <br /> Address �. N3 r�ZG 1 1?1 City } " <br /> Contractor's Name "17 `l cam, r License #jk22 Cftone cA <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / ar.e <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 <br /> Industrial Cable Tool Dia. of Well Excavation Azz <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 <br /> H.P. ("Z! <br /> PUMP REPLACEMENT: / / State Work Done V <br /> :REPAIR: <br /> /)(7 State Work Donee <br /> PES•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 ofm ow �ean� belief. I WZLL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A FINAL INS CTIO 't <br /> SIGNED TLE r <br /> WRAW PLO LAN ON R -RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,� DATE <br /> ADDITIONAL COMMENTS: IV -- <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 0­1l2.S <br /> E H 1426 Rev. 1-74 1-'F4 2M <br />