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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF 'ICESE: 1601 E. Hazelton Ave. , Stockton, Calif. �( <br /> Telephone (209) 466-6781 U <br /> all APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ae 9-7, <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 1 ��� �� RUS 1 11V, CENSUS TRACT <br /> Owner's Name bul�ue PhoneQ3+ 2 / <br /> Address & ,� S/ O, - 71 ' ,� City 7K)/(! <br /> Contractor's Name H )PJ � r License #ta- Phones,/5—//65 <br /> ,35: 59 <br /> o4rl <br /> © a 1p, &h": �lla 1. .6;3ti ra <br /> _ sT <br /> TYPE OF WORK (Check) : NEW WELL V� DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK IMf SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD � �y` 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 a�4 <br /> Domestic/private Drilled Dia. of Well Casing /44" <br /> Domestic/public Driven Gauge of Casing 3 <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 <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 /> informat o-ns true to, t arsof my k wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND A FI I <br /> SIGNED TITLE <br /> DRAW P$0 T PLAN ON REVTPISE SID <br /> dL FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP TION PHAS . III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ZZ DATE 3-�- <br /> E H 1426 Rev. 1-74 044,ru t aw T rrm wo e r346 2M <br />