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�I;_. aAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ .� <br /> ErOFFICEUSB: 1601 E. Hazelton Ave. , Stockton,; Calif. <br /> Telephone: (209) 466-6781 'r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �714 i <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 Riles and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION CENSUS TRACT2V <br /> � <br /> Owner's Names Phone" roe <br /> Address C;Zd 310 . � Jai i' ���L�� City <br /> � <br /> Contractor's Name 'E_2_929 �� License hone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/'7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other L/ <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 /> Industrial . Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing V. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout, <br /> Disposal Other Other Information ` <br /> -GeophysicalSurface Seal Installed BY: <br /> . i y <br /> h PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Do <br /> PUMP :REPAIR: L State Work Done <br /> FESRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1°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 FINAL INSPECTION. <br /> SIGNEDlaaal . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT IN§FEMON. ef VPHA I I FINAL INSPE ION <br /> INSPECTION BY DATE INSPECTION DATE /,�- l�-7 <br /> '4 E H 1426 Rev. 1-74 1-74 2M <br />