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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ���//� i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �191- � <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 Ru/Is and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /j r��-Y7 CENSUS TRACT <br /> Owner's Name Phone <br /> Address (tet.( ' IJJ City <br /> Contractor's Name c�( r G icense It.-V �pc{ Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION /) PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> 7-1 <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 <br /> Domestic/private Drilled Di.a. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical /Q7 Surface Seal Installed By: S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: =4 State Work Done xzli� 4 p ccc� <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 Distric <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 /> - <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING ANDA,-,)FINAL INSPECTION. <br /> SIGNED TITLE �� <br /> : RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1-;LIA <br /> 17-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION PHASE IJ/FINAL INSPECTIOIJ <br /> INSPECTION BY DATE INSPECTION BY DATE 17-117--l-2--7 <br /> �j/priwehvv) c� be 2ce"Ijv 4r.0, e/P e'cg/ ii,�77� 2M <br /> E H 1426 Rev. - 1-74 Pr meed j bpx t+Strc� d �t� 1r� "e/ Jc <br />