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SAN JOAQUIN LOCAL HEALTH DISTRICT 5 <br /> FO% OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> rAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 20-727 Z .4625CS' CENSUS TRACT <br /> Owner's Name /A L/ »n sy la K ,i` �j Phone <br /> Address City <br /> Contractor's Name i.�J� �t �/ License 1/-2fp Phone 2 -.;3I <br /> TYPE�OF WORK'(Check):. NEW WELL / DEEPEN:/-7-RECONDITION /7T DESTRUCTION /-7 <br /> PUMP. INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Othei <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY- <br /> SEWAGE <br /> RIVYSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE :`PYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool; Dia. of Well Excavation a <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing v <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection " Rotary Type of Grout <br /> Disposal Other Other Information <br /> i <br /> Geophysical Surface Seal Installed By: <br /> f , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumps H.P. <br /> I <br /> PUMP REPLACEMENT a,/_/_ -state,.Work_Done.._._ �-- - <br /> PUMP7REPAIR r.,-_, ' -"�- <br /> �State7Wark done` <br /> ,PESSTRUCTION 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' Heaith 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 "F0R A`GROUT INSPECTION <br /> PRIOR TO GROUTING AND AIN NSPECTION. <br /> SIGNED TITLE 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY `il/ DATJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I / INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />