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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: =f 1601 E. Hazelton Ave., Stockton, Calif. <br /> { Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermit No. 27- 38 ,V_P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1a-27 <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 �v� �'d-�' � �`�" I��% CENSUS TRACT <br /> 1 <br /> Owner's Name �� � " �r.. Phone <br /> Address _ ` �; �G.+ ��--�" City )171 <br /> � License #�c?6� Phone <br /> Contractor s Name �"� % ..._� <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN / / RECONDITION /_T DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT <br /> Other <br /> ,.a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS LP00 /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 <br /> Domestic/private Drilled Dia. of Well Casing o� <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 /> aX <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / State Work Done e " W <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 anew 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 GR UTING AND A INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN 0-� E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `�__._[a.-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE X11WFINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BYZ ice-72 <br /> E H 1426 Rev. 1-74 <br />