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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAL OFFICE 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 <br /> 1 YEAR FROM.DATE ISSUED Date Issued X71 <br /> (Complete In Triplicate) <br /> Application is hereby grade to the Sats 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 ./V/. 'Z lam. CENSUS TRACT <br /> Owner's Name ,t.s /cam /►f CG/ Phone <br /> Address .._ City <br /> Contractor's Name ' �9�� ¢�_._._._. License # Phone <br /> TYPE OF WORK (Check): NEW WELL /1. 'DEEPEN /7 RECONDITION /_7 DESTRUCTION _� <br /> PUMP INSTALLATION j9LPUMP REPAIR /_7 PUMP REPLACEMENT 17 <br /> Other /_7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> _&Q2LPIT PRIVY <br /> SEWAGE DISPOSAL,.FIELD_. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTt LINE - PRIVATE STIC WELL PUBLIC DOMESTIC WELL W. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -� <br /> Industrial Cable Tool Dia. of-Well Excavation <br /> .e_�Domestic/private Drilled Dia. "of Well-Casi:ig -V <br /> Domestic/public - Driven Gauge of_ Casingw..�_ <br /> Irrigation ,��Giravel Pack Depth of Grout Seal <br /> Cathodic Protection z---Rotary Type of Grout <br /> —Disposal -- ' <br /> Other � ether Information , <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ S[j.3 _ H.P. . n,e <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .RE.PAIR.o /? State Work Done _ <br /> ES•TRUCTION OF WELL: Well Diameter <br /> 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 GROUTING AND A FINAL INSPECTION. r <br /> SIGNED TITLE X12 i,C� ,e <br /> DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE ?-40-21- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PITASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / A - <br /> i E H 1426 Rev. 1-74 I-74 2M <br />