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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW"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 ;7--?-e-2 <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 trade 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 _ )� � ' . CENSUS TRACT <br /> Owner's Name D i CX ki Phone -2a,,2 <br /> Address '-f0 JO 1 UILL RZl/ }t,✓LG• City <br /> T_ <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION f <br /> PUMP INSTALLATION O PUMP REPAIR/-7PUMP REPLACEMENT /7 <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 DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> r..� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 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 Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor !i :cSv t�t��, ,y_ r► <br /> Type of Pumpf <br /> jr. i� �� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br />)ES•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 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 />'RIOR TO G OUTINGAND AIFINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ,FOVDRPARTMENT USE ONLY <br /> PHASE T / <br />!APPLICATION ACCEP /AL1 ffoT-/ DATE 7- zo— <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRANII311,PINAL INS PE I N <br /> INSPECTION BY DATE INSPECTION BY DATE . '` ' <br /> E H 1426 Rev. 1-74 2M <br />