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C� /air SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S:?3,6jo� <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 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 /> _ ,l�C�Cf C'� �r8o:©y n <br /> JOB ADDRESS/LOCATION Sn,. . €�Q.-,,� a iu1�pL'�y{- �•-�`(",.(,,' CENSUS TRACT <br /> Owner's Name r�lr! ��aky Phone <br /> Address City <br /> Contractor's Name 9 <br /> �`� '1tG Fri �Z% License # / j7�hone b <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7•RECONDITION '/7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 /> 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 <br /> Geophysical Surface Seal Installed By: O <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump h H.P. �! <br /> i <br /> y. <br /> PUMP REPLACEMENT: / / State Work Done` - - <br /> PUMP .REPAIR: / / State Work Done, �A�� <br /> )ESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> q <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 1 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> BELL DRILLERS,REPORT of the we 11 and notify them before putting.. the..well. in.use... .The above <br /> Cnformation' is true to the best of,"My owled a and b ief. I WILL CALL FOR A GROUT INSPECT IurI <br /> 'RIOR 0 TING A FINAL <br /> ;IGNED TLE S I <br /> (D T PL ON HEMS SIDS <br /> /R DEPARTMENT USE ONLY <br /> ?RASE I <br /> APPLICATION ACCEPTED BY <br /> =ITIONAL COMMENTS: ! <br /> PHASE IL GROUT INSPECTION PHASE NSPECTION <br /> INSPECTION BY DATE INSPECTION BY If zz Z& DATE <br /> E H 1426 Rev. 1-74 - __ .✓ U75 2M <br />