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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74-11q-RQ) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 the .San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q" !� ,CENSUS TRACT <br /> Owner's Name 1 Phone L4 ef c° <br /> e <br /> Address Z_ <br /> City <br /> Contractor's Name j s <br /> License honej <br /> TYPE OF WORK (Check): NEW WELL /Z?�- DEEPEN '/-7 RECONDITION /.-7 DESTRUCTION %]� <br /> PUMP INSTALLATION L� PUMP REPAIR /� PUMP REPLACEMENT f <br /> Other El <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 /> IndustrialCable Tool Dia. of Well Excavation (� <br /> Z--7-Domes tic/private Drilled Dia, of Well Casing 211, <br /> Domestic/public " 'Driven a k Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -Cathodic Protection"= •�_ �gRotarq Type of Grout <br /> ,Disposal: `�_ *` V Other Other Information <br /> Geophysical Surface Seal Inn�stalled <br /> PUMP INSTALLATION: Contractor ,Zy t <br /> - Type of Pump H.P. ,— <br /> PUMP REPLACEMENT: . i-1 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 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 belief. I WILL .CALL FOR A GROUT INSPECTION <br /> PRIOR TO GEWIAG AND A PIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />.PHASE I <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE- 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r` 4/75 2M �; <br />