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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. fl�p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k';,4?-& <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. 186 and the Rules and gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C% C - '✓ CENSUS TRACT <br /> Owner's Name / V!l � Z � Phone � f <br /> Address 5 O VA -�J .L.2 7J.1 f0._3-J City . -*-,f 7 cr-/P <br /> Contractor's Name2?4��j7 -`) 'Po t-) 7p-."5 License f �" PhondjJ <br /> TYPE OF WORK (Check): NEW WELL /- DEEPEN '/? RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ PUMP REPLACEMENT <br /> Other /7 I . <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 <br /> Domestic/private Drilled Dia. of Well Casing G� <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 H.P. s <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 /> information is true to the•best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS•. <br /> PHASE II ION PHASEAT11FINAL INSPECTION,, <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/7 2M <br />