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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • F08rOFFICE USE: _ <br /> -1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z 3,294) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,S-7 <br /> I (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 anis the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 7 ,-70 CENSUS TRACT <br /> Owner's Name Phone <br /> Address _ �eGAD <br /> City <br /> Contractor's Name 'c/4e al&V) License Phone �2: <br /> l' -4 <br /> TYPE OF WORK (Check): NEW WELL��DEEPEN '/7 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT -7 <br /> Other /% --- <br /> DISTANCE TO NEAREST: SEPTIC7_TANK. 9V SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-SPECIFICATIONS <br /> µ Industrial 'table Tool Dia. of Well Excavation— <br /> j <br /> - omestic/private _Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ICS <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> w Cathodic Protection Rotary - Type of Grout' <br /> Disposal Other Other_Information <br /> Geophysical Surface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor ati <br /> Type of Pump.,. : , <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP :REPAIR: /_7 State Work Done - r <br /> ES;TRUCTION 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 AAFINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> `" - , {DRAW PLOT PLAN ON REVERSE SIDLE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />��APPLICATION ACCEPTED BY DATE 2s� 71 r <br /> ADDITIONAL COMMENTS: [ <br /> PHASE II GROUT INSPECTIONPHASE,III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />'• 1-74 2M� <br />