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♦ / <br /> j/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/b -7p <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 Jopquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 Z C,A ri CENSUS TRACT <br /> Owner's Name) Lry Phone <br /> Address r,� 3 � /�`�/ ? ! / / � City t�Tf. N&N ) <br /> Contractor's Name aLfi l( WfU u1 P ('Q • License #/ 67— Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /� W <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY :t> <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 /> dustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing1JAI <br /> Domestic/public Driven Gauge of Casing &-16 <br /> Irrigation Gr ack Depth of Grout Seal :5-6 <br /> Cathodic Protection otary Type of Grout Zdy7' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP 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 omply with al aws and regulations of the San Joaquin Local Health District <br /> and the State of C liforn' pe aini g to or regulating well "construction. Within FIFTEEN DAYS <br /> after compl ion w6r)e o a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL S o e w 11 a notify them before putting thewell in use.. The above <br /> informati is tr t he st o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING D A INSPECTION. <br /> SIGNED TITLE (,(�hJ 1� 'A <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �o <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY M DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74 1177 2M <br />