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SAN JOAQUIN LOCAL HEALTH DISTRICT �� � �� �r✓ <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SCANN <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <br /> w, (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 /10 ? Am� CENSUS TRACT <br /> Owner's Name �y P �� S� �� _s Phone ,, 1z (e <br /> Address ,,,__z 7 —�1- ,�� City 77-6C 4't:DJ4 <br /> Contractor's Name � License # Phone 7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION //,,f PUMP REPAIR / / 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 <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /yoi <br /> Domestic/private Drilled Dia, of Well Casing %i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S"a �y- <br /> Cathodic Protection L,,," Rotary Type of Grout C�y,,Q .i_ <br /> Disposal Other Other Information <br /> —r— <br /> Geophysical Surface Seal Installed By:for <br /> PUMP INSTALLATION: Contractor .G <br /> Type of Pump ��..� 3Q6�iL1�� H.P. <br /> P MP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 GBQUTING AND A FINALI PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Z57 <br /> OR JDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l 9 <br /> ADDITIONAL CO TS: <br /> P*S.Ejil CROVT SPECTI N - P fi /FINAL INSP'ECT1€��— <br /> INSPECTION BY TE "� INSPECTION B ATE ,iq <br /> Wff� 531 E H 1426 Rev. - 1-74 <br /> b/77 2M <br /> _ <br />