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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOh'.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., - -z g <br /> 1 171 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued .o-a-7S-- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San .Joaquin Local Health District for a permit to construct <br /> unci/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 .pd the Rules and Regulations of the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J�50 -5 7 CENSUS TRACT <br /> Owner's NamePhone <br /> 4 Address 05- ��� �fc- �V-4 <br /> Contractor's Namer��>� �U�� ' _ License 46'�37�Pho <br /> TYPE OF WORK (Check): NEW WELL �y DEEPEN/? RECONDITION /? DESTRUCTION <br /> l PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT <br /> Other I / <br /> I 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 SPECiFICATIO S <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia, of Well Casing e <br /> ..-. Domestic/public Driven Gauge of Casing 7I' <br /> Irrigation Gravel Pack Depth of Grout Seal TO <br /> Cathodic Pr_otect_ion _Le, Rotary Type of Grout V <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION-. Contracto [/13 C_-2 r <br /> Type of Pump el Xg A.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 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 thein before putting.the..well. in.use... .The above <br /> information is true to the-bes t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I SIGNED TITLE <br /> t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> {{ FOR DEPARTMENT USE ONLY <br /> i. PHASE I f <br /> APPLxcAT IO •'� DATE 'N ACCEPTED � .�-- ` - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -} INSPECTION BY DATE <br /> E�H 1426 Rev. 1-74 r - ...ellly-1r- <br /> ' r ' <br />