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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: k11,1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (269) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .ig <br /> THIS PERMIT EXPIRES I 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 /' �j U e rL.. CENSUS TRACT <br /> Owner's Name Phone ` <br /> Address City <br /> .- + --,�,,, "E ` r' ��s License �#?��J rad" Phone <br /> /1 . <br /> Contractor s Name �� ��.r/ -.s%��'d �` . " � <br /> cr <br /> TYPE OF WORK (Check.) : NEW WELL '/—/ DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7 , <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �, y <br /> 4 ; SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT BOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL _ PUBLICrDOMESTIC_WELL _ _ N <br /> INTENDED USE TYPE OF WELL CONSTRUCT-ION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well.-Ekcavation <br /> Domestic/private 4 Drilled Dia, of Well Casing <br /> f Domestic/public f Driven Gauge°'of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other �_ Other Information <br /> Geophysical Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V� H.P. <br /> PUMP REPLACEMENT: / State Work Done f� �* - " '` rT �- �<72-7 1 <br /> PUMP .REPAIR: ' _ ` State Work`Done <br /> DESTRUCTION OF WEL'11: Well ;Iliameter Approximate Depth <br /> t Describe Material and Procedure <br /> f.I hereby -agree. to. comply with all laws and regulations of the San Joaquin Local Health District <br /> land the Stag of California pertaining to or regulating we11'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 wellin 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-FTNAL INSPECTION. <br /> I <br /> SIGNED � �''y - � t �.�r r TITLE -Cl-t-f V4 --- ---- <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R FOR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTIONPHA III/ ,= N INSPECTIO <br /> INSPECTION -BY DATE INSPECTION BY DATE <br /> f/ L! 4j <br /> E H 1426 Rev. 1-74 �- <br />