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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QFFICE 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 <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 Rules and Regulations of the San Joaquin Local-. Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> I <br /> 4 <br /> Owner's Name �/'S, e0.,/?0R �}�Q f-f to Phone <br /> Address 7 d p U t h A // of t City <br /> Contractor's Name License #;�/.V_f22_Phone K3.2, 7 f2f <br /> / it <br /> TYPE OF WORK (Check) : NEW WELLp DEEPEN/ / RECONDITION / / DESTRUCTION /_7PUMP INST LATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD i� 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 1.2 <br /> Domestic/private J—Drilled Dia. of Well Casing rr <br /> Domestic/public Driven Gauge of Casing a <br /> Irrigation Gravel Pack Depth of Grout Seal -57 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: aL_( 7�� a <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 Q 4 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A.FINAL INSPECTION. <br /> SIGNED Q� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B, c DATE J-7 — <br /> ADDITIONAL COMMENTS: 41Z11 JI <br /> PHA§ JI GROUT INS_ECTION PHAS ' T .I/F' NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE77-- -.5--,7 7 <br /> E H 1426 Rev. 1-74 5�� ism / 1Z/ <br />