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SAN JOAQUIN LOCAL .HEALTH STRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. : S.tockton, 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 ,4-?-,?Z <br /> (Complete In Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and. Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION . `�j Af7`d �o�a�l _- — CENSUS TRACT <br /> Owner's Name la ,. Phone VZ — 2:7 2 <br /> AddressCity ? .s c :;,,_-� <br /> Contractor's Name1Jam,+ c n L r]u ev � CT. License #2.45:7,1,1 Phone =f*W <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 14--7-- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �I <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 <br /> Irrigation , Gravel Pack Depth of Grout Seal FT <br /> Cathodic Protection Rotary Type of Grout , O <br /> Disposal Other Other information <br /> Geophysical. Surface Seal Installed By-: <br /> PUMP INSTALLATION: Contractor 1/"�.r <I' <br /> Type of Pump u b H.P. <br /> PUMP REPLACEMENT: / / State Work Done k` <br /> zz, <br /> PUMP .REPAIR: / / State Work Done � ! <br /> t <br /> ;� ,�-� <br /> DESTRUCTION-0F_wWELL-:-�---We-11 biameter"�-- PP P <br /> Describe Material and, Procedure , <br /> I hereby-agree—to-comisly`with-all laws "and regul`Ations--bf`-the Sae Joagiiin '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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> FOR DE ARTMENT USE ONLY <br />,PHASE I (.1 /7 ./77 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE' II GROUT INSPECTION PHASE II /FINAL INSPECTION <br />:INSPECTION BY DATE INSPECTION BY DATE-- F� 7 <br /> 4 � ,X77» _ � <br />' -wE H 1426 Rev. 1--74 <br />