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SAN JOAQUIN LOCAL HEALTH DISTRICTi r <br /> Fo�.oFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. gz <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z ff/I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or instal, 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 S CENSUS TRACT <br /> Owner's Name Phone /�C 9 <br /> Address ` <br /> City <br /> Contractor's Name _ ,� ", R_A��ak ._ License # 37 Phone s <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN/-' RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSfiALLATION / / PUMP REPAIR PUMP REPLACEMENT J f t <br /> Other <br /> v1 . <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 l 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information I <br /> Geophysical Surface Seal Installed B ! <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,.REPAIR: a-e�.LR a- e v�C� �i`o 1 l Q � <br /> / / State Work Done <br /> t <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 Di—st-r-11CIV w <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after comp:Letion of my work on a new well., I will furnish the San Joaquin Local Health District a 1 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in .use.... The above r <br /> information is true to the-best-of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I <br /> R DEPARTMENT USE ONLY <br /> ii.'PLICATION ACCEPTED BY BATE <br /> WDITIONAL COMMENTS: + <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br />�1+TSPECTION BY DATE INSPECTION BY DATE d <br /> /0 s'� i Th a/ pfd ,rte <br /> E H 1426 Rev. 1-74 � .y �c:� .?rte/� l/�'-/�-� �9� !,/7c: 9M <br />