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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �j z <br /> # APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�/ `✓� <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FR0_T.t DATE ISSUED Date Issued 7 <br /> i (Complete In Triplicate) <br />!, Application is hereby made to the Sakti 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 Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI I <br /> CENSUS TRACT gdLQ 1V' <br /> Owner's Name F' ' Z fi Phone �rv <br /> -. <br /> Address <br /> i - City2z&",5�v ICEA. CA, <br /> Contractor's Name-- "� ,m� �, License ,# 3Phone <br /> - SW1-U3ra� <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / RECONDITION / / DESTRUCTION.J-7 - <br /> PUMP INSTALLATION /PUMP REPAIR ./ / PUMP-"REPLACEMENT� /7 <br /> Other ;/% <br /> I <br /> DISTANCE TO NEAREST: SEPTIC ITANK d7t C SEWER LINES lx-v-PIT PRIVY <br /> SEWAGE DIS OSAL FIELD q_CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> !/ Domestic/private I Drilled Dia. of Well Casing S� <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal �Q <br /> Cathodic Protection <br /> otary Type of Grout <br /> tea- C o�V-C <br /> - Dispos•al- . _ _ :.,F_4. O-ther _ . __-- Other ..Informations <br /> _._Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor y . <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done <br /> .DESTRUCTION 0_F-mW-ELL-:--Wet-l.�Di-ameter Approximate Depth r <br /> � Describe Material and Procedure <br /> r <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 compleion of my work on�.a�new well,, II will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting- thee:well -in use. The aboV0 '' <br /> inf ton is true to, the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR �IRUTING AND A ECTIO <br /> SIGNED ; TITLE(-- PL.T PLAN 'ON RE FRSE SIDE) ' <br /> ( . ,_ <br /> # FOR DEPARTMENT USE ONLY { <br /> PHASE I50 <br /> ; <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: [ F <br /> PHASEGROU INSPECTION PHASE II FINAL INSPECT N F <br /> INSPECTION BY DATE y X.;- -.INSPECTION BY DATE ' <br /> wall 7.4 r <br /> E H 1426 Rev. 1-74 3/76 2M <br />