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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT P rmit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedo2 <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 9 '3 �LCENSUS TRACT <br /> Owner's Name /,�-eL4, QrL, Phone~^/_X5 czZ <br /> Address City <br /> Contractor's Name License #,&_07 � Phone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION XT <br /> PUMA INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT f� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOS*FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL-�� PUBLIC DOMESTIC WELL � y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation t� f <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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ t�ri.�'irx sy{ rl H.P. <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter �i Approximate Depth <br /> Describeptilia d rocedure <br /> I hereby agree to comply with all aws 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 w well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the 1aid notify thein before putting the-.well.-in use. The above <br /> information is true to th est knoxl.edge and belief. I WILL CALL. OR A GROUT INSPECTION <br /> PRIOR TO GROUTI D INSPECT N <br /> SIGNED TITLE <br /> i ( W PLOT PLAN ON REVtRSE SIDE <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -�-1 <br /> ADDITIONAL COMMENTS: <br /> P GROUT INSPECTION P S FINAL INSPEC ION p <br /> INSPECTION BY - DATE =�-7g IN5PECTION BY DATE -n-1a <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />