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SAN JOAQUIN LOCAL HEALTH DISTRICT P10. b ox GOO <br /> FO> OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. l <br /> Telephone: (209} 466-6781 Maolee4j e; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> ' f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �/ <br /> ' ff (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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name -e 4- Phone <br /> Address _a 7 L�iyt� �Cl.• City L'� <br /> Contr or's Name Pd, �QJ, ,7,��, License17hone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION 2E4 _PUMP REPAIR / / PUMP REPLACEMENT J_7 <br /> Other /. J <br /> DISTANCE TO NEAREST: SEPTIC TANK [/�'p SEWER LINE PIT PRIVY <br /> SEWAGE :DISPO AL `FIELD 4e � 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 16 f' <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation ravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout V Off <br /> "Disposal Other Other Information <br /> Geophysical. Surface Seal In B <br /> PUMP INSTALLATION: Contractor f! �� �• - / C <br /> eA <br /> Type of Pump H.P. S` <br /> T—T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP.,.REPAIR: / / State Work Done <br /> DESj1iUCT_ION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 OUTIN AND A FINAL INSPECTION. <br /> SIGNED o I TITLE !-rS�w,yY�'77�.�a <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i. FQR DEPARTMENT USE ONLY <br /> PHASE Of <br /> APPLI ON ACCEPTED BY DATE <br /> ADVTIO AL COMMENTS: t <br /> PHASE 11 GROUT INSPECTION P III/131ONAL INSPECTI017 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 214 <br /> E H 1426 Rev. 1-74 <br />