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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17-111 73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 '7, <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. 18622 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION -� �f�f .h r ' � CENSUS TRACT 0Q`7-- 0`40-2k <br /> Owner's Name Phone <br /> Address City <br /> Contractor's NameI , <br /> Uy Yl'L Lc, ` License hone 1: „�f <br /> X <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION 1 PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK ( SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSE�}}'' FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE[WFRIVATE DOMESTIC WELIAK—f—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 Z 4 `\ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> F Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 14 10&-y .4" $' <br /> Type of Pump F H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <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 we11 ''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 GROUTING AND A FINAL INSPECTI <br /> SIGNED ITLE X <br /> (DRAW PLOT PL REVERSE SIDE <br /> PHASE I <br /> FOR DEPAkTNENT USE ONLY <br /> APPLICATION] ACCEPTED BY 11AA4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTI NLt4s,F III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE p �� <br /> E H 14215 Rev. 1-74 214 <br />