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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFiOFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> II :. Telephone: (209) 466-6781 <br /> ;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> r t 7G- 6 97 <br />' THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7-30,7 <br /> (Complete In Triplicate) <br /> Application is hereby Ade to the Sart Joaquin Local Health District for a permit to construct <br /> and/or install the work11herein 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 CENSUS TRACT <br /> Owner's Name _&W,)yt Mt JCS_ - Phone , Z6 a 7 <br /> Address ,+d»-m^e- I City <br /> Contractor's Name License # PhoneeliQW <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/? RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION / J PUMP REPAIR .g7 PUMP REPLACEMENT <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 11 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 12\) <br /> Industrial Cable Tool Dia. of Well Excavation °c <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-o£_;Grout <br /> Disposal` T '"` ~Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> i � <br /> Type .of Pump H.P. <br /> t PUMP REPLACEMENT: . �!/ State Work Done <br /> PUMP �REPAIR - . <br /> State Work Done <br /> IN t <br /> DESTRUCTION OF WELL: Well Diameter 5;. 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 pertainin-9--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 offthe 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 FOP, A GROUT INSPECTION <br /> PRIOR TO GARTING 'AN !IIF NAL INSPECTION. <br />" SIGNEDTITLE <br /> 4 (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' <br /> PRASE I s R DEPARTMENT USE ON <br />' � ?� FO� ONLY <br /> P <br /> I APPLICATION,ACCEPTED ,BY ,. DATE <br /> ADDITIONAL COMMENTS:+. <br /> PHASE II GROUT INSPECTION PHAS FI INSPECTI <br /> INSPECTION BY 1p DATE INSPECTION BY DATE <br /> . PI <br /> E A 1426 Rev. 1-74, rr h/75 2M <br />