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iSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh7QFFIfi. USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 y cIrt <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 Aereby 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 Q CENSUS TRACT <br /> Owner's Name A4E,0A1j4Aj1PhonegF- 1- ,-� <br /> j 14 <br /> Address City ' <br /> l <br /> 1V�____.__j�i,Q- _.._. ��.�' <br /> Contractor's Name License k // Phone - <br />> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL"LATION / / PUMP REPAIR,/--/—, PUMP REPLACEMENT /_7 <br /> Other <br />{ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINESjI PIT PRIVY �— <br /> F a SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT , —OTHER <br /> PROPERTY LINE W'PRIVATE DOMESTIC WELL AW- ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ /r C <br /> Domestic/public Driven r Gauge of Casing <br /> �[ IrrigationGravel Pack Deptii of Grout- Seal VV <br /> Cathodic Protection Rotary- Type of_.Grout ---- <br /> —Disposal Other Othertlnformation <br /> 4 Geophysical Surface Seal installed B <br />! PUMP INSTALLATION: Contractor e ` S <br /> t Type of Pump �_" H.P. <br /> PUMP REPLACEMENT: / / S tate Work Done j 177- <br /> PUMP' <br /> 7 -'`PUMP''REPAIR: - <br /> / / " State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ .r-� "' ��"`'^^-- .� Approximate Depth <br /> 4 Describe Material and;Pkocedure <br /> II hereby agree to comply with all laws and regulations-b f-the-Sao, Joaquin Local Health District <br /> and the'State of California pertaininglto or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnishfthe;-S'an 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 es of my ncwledge-iand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR NG AFI AL SP ION. r <br /> SIGNED <br /> TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I r ,. <br />:APPLICATION ACCEPTED BY: DATE <br />`ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION' - " - _ PHASE " I/FlNftL INSPECTION <br /> INSPECTION BY ATE x . 4% INSPECTION. BY / `� DATE <br /> y <br /> E H 1426 Rev. 1-74 � �S� � �-`�`� 1177 zKF, <br />