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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FORtOFFICE DISE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X51/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Rate 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 /> II JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name 0 a <br /> G <br /> Phone,- <br /> Address: D 7 &W7-jCity'-`-/Lt <br /> Contractor's Name. 1,0y 1`71p, License/4--137-1 Phoneme <br /> j TYPE OF WORK (Check): INEW WELL /_7 DEEPEN -/77 RECONDITION 17 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLA�T /—f <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 j Drilled Dia, of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> ,Irrigation ,M Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> —Geophysical.' <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J// State Work Done <br />- :REPAIR• .... . �_ <br /> 'L7- -State Work-Done:. <br /> �I <br /> ESjRUCTION 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 <br /> ''- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 29 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , <br /> DATE # <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE 1114EINAL INSPECTIO <br /> INSPECTION BY i. DATE - INSPECTION. BY 2- DATE <br /> E H 1426 Rev. 1-74a <br /> IL 1-74 2M <br />