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SAN JOAQUIN LOCAL HEALTH DISTRICT ) G <br /> F(w$+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? - 5—s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 12-3-7tj <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 l7,:�G �y� CENSUS TRACT <br /> Owner's Name .�Q ';9I7 L Phone 76 `) <br /> Address 7 �30 city <br /> Contractor's Name �� L�� iDl/ `� License #/6-1-373Phond"/5rX-d-er <br /> TYPE OF WORK (Check): NEW WELL/-T DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR J- PUMP REPLACEMENT /7 <br /> Other / / <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 7W State Work e- Td <br /> RES®RUCTION 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 t tir, . nn ( £ V> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED L� DATE /1 7 .� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-'-INSPECTION PHASE F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />