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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk.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 Issudd Z-1Z- 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 / 496675- Sp. 4US-r//gyp CENSUS TRACT <br /> Owner's Name 6,60RWE d?APADQt,?'L/S Phone 2-32•- <br /> Address o, 44A;T& 'RA. / A-V7"AQ4 City NT,EG� <br /> Contractor's Name /(/[ ,!¢C/< A&Llboo License #:I <br /> s Phoney?FJ <br /> TYPE OF WORK (Check) : NEW WELL 49 DEEPEN / / RECONDITION /-/ DESTRUCTION /-7 <br /> PUMP INSTALLATION _/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / U1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 70-' SEWER LINES 124r/ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ��) CESSPOOL/SEEPAGE PIT�� OTHER <br /> PROPERTY LINE& PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 0 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 - y Rotary Type of Grout danz Wee <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: iVQC(� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,$URM 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 DAIS <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 GRQ2CING AV A NAL INSPE ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYza DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FI AL INSPECTIO <br /> INSPECTION BY DATE f, INSPECTION BY DATE f <br /> E H 1426 Rev. 1-74 c 1f77 .�" SNI <br />