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SAN JOAQUIN LOCAL HEALTH DISTRICT O <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. 7'�lpv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued La _5 17 <br /> k (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 s � u v er CENSUS TRACT <br /> Owner's Name 'pCl Phone 'Sps _9 t((6 <br /> Address ()I- City <br /> Contractor's Name License #z_011aPhone6g5 - L6,— <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /,_DEEPEN / f RECONDITION / / DESTRUCTION 1'7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKQO SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ftPf CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL L2e PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p' <br /> Industrial Cable Tool Dia. of Well Excavation blit/ \ <br /> V/ Domestic/private ✓Drilled Dia. of Well Casing ^te _ <br /> Domestic/public Driven Gauge of Casing ! Lea 4� C <br /> Irrigation Gravel Pack Depth of Grout Seal 5C2 <br /> Cathodic Protection �� Rotary Type of Grout <br /> Disposal Other Other Information agAt <br /> Geophysical Surf ace_Seal Installed By: <br /> PUMP INSTALLATION: Contractor S <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 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 FI AL INSPECTION. <br /> SIGNED TITLE a[PIdJ <br /> ` D W PLOT PLAN 'ON RE- TERSE SIDE) T _ ^'"' k ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY kn& DATE 7 7 <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FhINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> yl 7/7S Wf", M14-6ti"l oGv�, e,, ,,,,,� 3�7 / <br /> E H 1426 Rev. 1-74 �, ..,r, o ^ . �u�{� .�,l� r� I�xo�-�v..eb ; <br />