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LO rn �a C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF011tO FILE USE: 1601 E. Hazelton Ave. , Stockton, 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 <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of-the4;San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "p 1.#*We, _� ib�yYi�iall�r:1 5� �. ,.�in Qrjlt�- CENSUS TRACT /&-7r 370- o-? <br /> ry <br /> Owner's Name _ <br /> �4 �l�� I r2.A,> , � Phone <br /> Address 7 a ko City <br /> Contractor's Name License #1 _.;12Z 'hone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN I=T RECONDITION /=7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / f PUMP REPLACEMENT /? <br /> Other / I <br /> j 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. of 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. . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 44.. <br /> Type of Pump H.P. 40 . <br /> PUMP State Work Done i lVs+r.�-fit <br /> PUMP''REPAIR: /7 State Work Done <br /> ,RES�RUCTION OF WELL: .Well Diameter Approximate Depth � <br /> { <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 knowled_ and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR ING. AND A- FINAL I 0 <br /> SIGNED ITLE 4i�,.f"" <br /> ( RAW OT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k APPLICATION ACCEPTED BY DATE � � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY w DATE .3 -;-6 -/ <br /> Sty .E S 1426 Rev, 1--74 1-74 2M <br />