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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 S� 7-/7 <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 1 I(`- y�-��L� Pd CENSUS TRACT <br /> Owner's Name Phonet5k " , SCS <br /> Address1 . City s:� c... <br /> Contractor's Name / :; ;ri'/� �% ��/ License �f r'�jG'1 G? PhoneIle_ z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 r C <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> c° ther / J� 'c 4AF C C I <z `S 4` <br /> �r Ir <br /> DISTAXM TO NEA ST• EPT TANK SEWER LINES PfT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER QZ1 <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 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4e <br /> on <br /> PUMP .REPAIR: / / State Wor e/ <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 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 A4D A FINAL INSPECTION. <br /> SIGNED .. .. TITLE ;r. --- <br /> '' (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY C DATE _ <br /> ADDITIONAL COMMENTS: aT�9 <br /> PHASE II GROUT INSPECTION PHASE I14XINAIOINSPECTION INSPECTION BY DATE `_�f�// INSPECTION BY DATE -1 :21 <br /> E H 1426 Rev. , 1-74 <br /> Tom`- ,/77 <br />