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- i <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOErOFFCE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209)' 4bf 6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete_ In Triplicate) � <br /> Application is hereby made tolthe San Joaquin LocAl Heglth 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 O., R CENSUS TRACT <br /> Owner's Name <br /> ���u Sc „ Z-" Phone 63-9 a 9 7 7 <br /> Address SA . : - City Z_- 5 r_,0j4,v <br /> Contractor's Name 7;17. ScAvv4So-;u License #a79010 Phone.. FL� <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN I_T� RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / SUMP REPAIR REPLACEMENT /? ; <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'i,INES PTT PRIVY ' <br /> SEWAGE DISPOSAL FIELD `r CESSPOOL/SEEPAGE PIT OTHER --� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'S PUBLIC DOMESTIC WELL X_ <br /> INTENDED USE TYPE OF WELL r,.l CONSTRUCTION SPECIFICATIONS I <br /> Industrial Cable Tool Dia. of Well Excavation rhI <br /> �T Domestic/private Drilled Dia. �of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation F Gravel Pack Degth of Grout Seal <br /> Cathodic Protection i Rotary Type of...Grout <br /> ,Disposal '., *k* : L ._ ; Other '�Othet in <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION.:.f# rContradtor. _ ~" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> Yt State Woxk YDone'%8 ff0..Poe- . —1-0S <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> --Describe"Mtarial$nd•-:Procedure9- - --� <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 Ifurnish 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 YOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND AFINAL INSPECTION. <br /> SIGNED TITLE <br /> V 4- <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED"BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE v-1,-/2.s <br /> i E H 1426. . Rev. 1•-74 1-74 2M <br />