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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0VOFFIC� E+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 ,s,�r?Gz:7s <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 <r��2�?� �� p, ��� $� L,/n)„ j�llEA/ CENSUS TRACT <br /> Owner's Name t R A A.,1< Phone <br /> Address l3/817 1 Ro <br /> City <br /> Contractor's Name T. S �,�, _�So e License # d 7gUly Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /? DESTRUCTION f7 <br /> _0PUMP INSTALLATION �/ PUMP REPAIR PUMP REPLACEMENT <br /> Other Y 0_ S RS i i CX w Eli . <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 <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 v � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / l State Work Done <br /> PUMP :REPAIR: / State Work Done <br /> ,RES-TRUCTION 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 thewell 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 4, <br /> _ (DRAW PLOT PLAN ON REVERSE SID <br /> &5*/? <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / `���✓�- <br /> ADDITIONAL COMMENTS: ,2 <br /> PHASE II GROUT INVECTION PHA I FINAL IRSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -Z 9-95-- <br /> E H 1426 Rev. 1-74 1-74 2M <br />