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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED °Date Issued 7 J9 26 I <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 'drAnance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ I Cf A)&i;TJI ,` � CENSUS TRACT <br /> Owner's Name I� IV�, k�, Phone q 3 f 3 )�f <br /> 'Address On T- i Ti� o) l o City ' 6T6 10 <br /> i <br /> �� <br /> Contractor's Name, �, � „ �° �' License # Phone <br /> �� �. 42�9 1 <br /> TYPE OF WORK (Check) NEW WELL / DEEPEN '/? RECONDITION / DESTRUCTION // <br /> PUMP INSTLATION "/ / .PUMP REPAIR /� PUMP REPLACEMENT /7 J <br /> Other /� -- <br /> i <br /> 1 <br /> DISTANCE TO NEAREST: , SEPTIC TANK _3W SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -_.PRIVATE._DOMEST.I.C_WELL­ —PUBLIC-DOMESTIC--WEAL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrial Cable Tool Dia.-of Well Excavation y[L <br /> Domestic/private Drilled "" Dia: of-We11 Casing <br /> Domestic/public Driven - Gau a of.�Casin <br /> Irrigation f Gravel Pack Depth of•Grout Seal AS 4"o NIN <br /> Cathodic Protection---- R-ot4xy °:; :Type of Grout ju <br /> T- <br /> .Disposal osal Other ether" Inf"o"r'•mation <br /> Geophysical ` Surf-ace Seal Installed By <br /> PUMP -INSTALLATION: ' Contractor w <br /> Type of Pump ' ..,. :, HP: <br /> PUMP REPLACEMENT: %/AY' State Work Done <br /> PUMP ,REPAIR: 1 ; . . <br /> } %/ State Work Done <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> 9 1 <br /> I hereby agree to comply with all ,,7.aws 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--ander--notify-them-before=putting °the�-weli�- n`�us..- `The 'above• <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A "GROUT INSPECTION <br /> PRIOR TO GROIJOING AND '.AFINAL, INSPECTION. <br /> SIGNEDTITLE14 <br /> 6, -DRAW-PLOT PLAN ON REVERSE SIDE <br /> 9 FOR DEPARTMENT USE ONLY <br /> PHASE _i + r. �...._ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE TI `GROUT INSPECTION PHASE4Ij/FIXAL INSPECTIO <br />'. INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 hhc5 2M <br />