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SAN JOAQUIN L0 HEALTH DISTRICT ��^ �`'�14 <br /> FO&;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a i 7u) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued c,-IS- <br /> (Complete <br /> 1S-(Complete In Triplicate) <br /> - <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 Reg lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U> G� CENSUS TRACT <br /> Owner's Name + .r raa�/ ,�, rte, 4 r, Phone Q' - 0 7 <br /> Address _ >,�� ..__. - City nth 6 ,�-yds <br /> Contractor's Name License # 1167a f Phone <br /> TYPE OF WORK (Check): NEW WELL /) DEEPEN /7 RECONDITION-17--DESTRUCTION _-- <br /> PUMP INSTLATION / / PUMP REPAIR /? PUMP REPLACEMENT 17 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER °�) <br /> PROPERTY LINE -. PRIVATE DESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL OMCONSTRUCTION SPECIFICATIONS <br /> Industrial etc � Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing a �► <br /> Domestic/public - Driven Gauge of Casing /d Vis.- RA , IWV <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protections Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: Qtc_aj <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 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..wel1 in-use... The above <br /> information is true to the-beat of my:knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. r <br /> SIGNED 1 TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE (9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 19S IN INSPECT <br /> INSPECTION BY DATE INSPECTION DATE <br /> 01 <br /> E H 1426 Rev. 1-74 2M <br />