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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ZFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. 1 <br /> Telephone: . (209).!466-6-781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP mPERMIT Permit No. <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED t a< Date Issued <br /> (Complete In Triplicate)' = s <br /> Application is hereby made to the San Joaquin LocaluHeal;th,District -foar a .permit to construct ! <br /> and/or install the work herein described. This application As made.••inicompliance with San Joaquin % <br /> County Ordinance No. 1862 and the -.Rules and •Regulations-of thetSan.3oaquin•Local Health'District. <br /> JOB ADDRESS/LOCATION U J - s _.` . -* CENSUS. TRACT- <br /> Owner's Name - YA1v,ES 66U Vim C= Phone 3 b ( <br /> Address City , (L n)j2fV <br /> Contractor's,Name I .�.;f n,v _ License #Q 9010 Phone - O <br /> TYPE OF WORK (Check}, `NEW°`WELY: %T" DEEPEN /_. RECONDITION /7 DESTRUCTION %, <br /> PUMP INSTALLAT--ION / /,f PUMP REPAIR PUMP REPLACEMENT , 4 <br /> Other / / <br /> S . <br /> 4 <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. o€ .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 kSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> REPAate Vo Woxk'D'one'�" .:.-.---,�., <br /> Pt}l IRi <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 beli.ef'. I WILL CALL F .-A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND FIWj INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . X9 6; DATE <br /> 4//.4,( 2 — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I CTION pHAM Igi.ZINAL INSPECTION �• <br /> INSPECTION BY DATE INSPECTION BY DATE gI4� <br /> E H 1426 Rev. 1--74 1-74 2M <br />