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`A^ ' SAN JO,.QuIN LOCAL HEALTH DISTRICT <br /> FOfi 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 l , X16 <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 Ru aRe tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q�lcCrT:�'�_ ' ,ti'nEV/,f 0/11,41J71 1 ""F'- n ddCENSUS TRACT <br /> Owner's Name `.�� � 6�! N d1i Phone '.' <br /> Address �, <br /> =.�l city. ' <br /> Contractor's Nacos License # Phone <br /> J <br /> TYPE OF WORK (Check): NEW WELL"/W- DEEPEN '/? RECONDITION /_j DESTRUCTION /7 <br /> PUMP INSTALLATION L� PUMP REPAIR /_7 PUMP REPLACEMENT 9 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6'0l+ - PIT PRIVY <br /> SEWAGS DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Gable 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 kl Rotary Type of Grout <br /> _,,,_,.Disposal _.- Other Other Information - � <br /> Geophysical Surface Seal Installed By: <br /> a <br /> +azv3lr_�. A <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.Y. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP_.REPAIR: /7 State Work Done <br /> tREESi RUCTION OF WELL: Well Diameter <br /> .,.-� 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 GRM INSPECTION <br /> PRIOR TO GROUTING AND A FINAV INSPE97ION <br /> SIGNED TITLE,Ljj <br /> DRAW WT PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> 1 GOUTINSPZCTIO PHAS IPBCTI <br /> INSPECTION BY DATE INSPECTION BY E _ <br /> E H 1426 Rev.-I-74 It 5 2M <br />