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SAN JOAQU`1N LOCP',.. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71-1�Ow <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j/ <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 trade incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r CENSUS TRACT ' <br /> Owner's Name ELIPhone , `6 <br /> Address <br /> City <br /> Contractor's Name <br /> License # Ij0 Phone <br /> TYPE OF WORK (Check): NEW WELL, X-7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION /-T f <br /> PUMP INSTALLATION/ / PUMP REPAIR/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> v SEWAGE DISPOSAL FIELD - - CESSPOOL/SEEPAGE PIT OTHER"--- <br /> PROPERTY <br /> .._. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL_ ..PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial xCable 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 <br /> Cathodic 'Protect_ion Rotary Type of Grout <br /> Disposal Other Other Information ' j <br /> Geophysical Surface Seal. Installed 'B t I <br /> F �'aSS 1 8 �T' y3I�S cr Fa v S U n (Vl 6 P 18 <br /> PUMP INSTALLATION Contractor <br /> Type..of. Pump H.P. . <br /> PUMP REPLACEMENT: . /moi//' State Work Done <br />'PUMP REPAIR:' .State Work- Done <br /> • I <br /> DESTRUCTION 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 /> aftet4lea ldtidi of -my work on a riew well, I will 'furnish the San .Joaquin Local Health District a <br /> WELL_DRILLERS._REPORT.of.the -well and ,notify. them before "putting;. the.vell. 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 ,Q/ti <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -_T „ DATE `/- <br /> ADDITIONAL COMMENTS: ' ..,,,.. .,._,_.......,.. ._ <br /> PHASE II GROUT INSPECTION PHASE,AIMINAL INSPECT N <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> E H 1426 12A,- 1 7� puu•4 � �Y� d�'-/ I�/?1� 9M <br />