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1/ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: C 1601E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7�.fjo <br /> THIS PERMIT EXPIRES"l YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby madesto 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 - f y �r ��,.- ���g /,y t2NSUS TRACT <br /> Owner's NamePhone 9�s/ -- - 7:5 <br /> Address _�f es_& 0 . 11 .�e e A-t �'Z, „ . 1-- - City <br /> Contractor's Names,f�'f �• �'� - License Phone,4 <br /> TYPE OF WORK (Check;y NEW WELL '/ / DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT IZ7-- <br /> 4her <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 /> k INTENDED USE r 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 OQ <br /> ---.A,,: ; Gravel Pack Depth of Grout •Seal v <br /> Cathodic Protection Rotary,—Type„_of Gr..out.,.-.�- <br /> Disposal Other Other Information pv' <br /> Geophysical, Surface Seal Installed By: , <br /> 4 ; <br /> It <br /> PUMP INSTALLATION:' 'l Contractor <br /> Type of Pump � , H.P•. �-- <br /> PUMP REPLACEMENT: ° /.7 -Stat"e Work Done <br /> PUMP .REPAIR: f / ' / State Work Done <br /> DESTRUCTION OF WELL:— Well Diameter ApproximatenDepth <br /> Describe Material and Proceduret , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local.Health District <br /> and the State of Californias{pertaining to or regulating ;Well '-construction' . Within FIFTEEN DAYS <br />' after completion of my work�'on�a,,pew well, I will furnish"lthe San Joaquin Local Health District a. <br />� WELL DRILLERS REPORT of the_ we11 'andfnotify them before puttt/ing. 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. t <br /> SIGNED ('�,, - _ _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED, BYDATE II "��, <br /> ADDITIONAL COMMENTS: t 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY # DATE INSPECTION BY ,��^%` DATE '•, � <br /> 1777 2M <br /> E H 1426 Rev.i 1-74 = <br /> _ ' <br />