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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F(F - FFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> VVV Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]S=�/9Le-1 <br /> li <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued La- <br /> Triplicate) <br /> ► (Complete In Triplicate) it , <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 bSn, joaquin Local Health District. <br /> JOB ADDRESS/LOCATION/,' CENSUS TRACT o25-O� -az <br /> Owner's Name /u U Phone - R6/ <br /> I <br /> Address i� 6at)( 6 9 7 City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/_7 RECONDITION /7 DESTRUCTION k7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT' <br /> Other /_7 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, 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 4 <br /> Domestic/public Driven Gauge of Casing !E <br /> Irrigation r Gravel Pack Depth, of Grout Seal <br /> Cathodic Protection Ratary Type 'of Grout- <br /> E Disposal Other Other Information <br /> Geophysical Surface Seal InstalledB. y: ;f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumps. . x H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 ' State Work Done <br /> I <br /> ,SES. RUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Ptocedure <br /> I hereby agree to complywith all laws' bnd regulati sf the Local Health District <br /> and the State of California pertaining to or r`egulat.ing 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: <br /> SIGNED TITLE 4� a&:d I--_ --- - - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) M <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> C APPLICATION ACCEPTED BY L v DATE <br /> i ADDITIONAL COMMENTS: it <br /> PW&VTIW0-U7 INSPECTION PHMVE III N INSPECTIO <br /> INSPECTION BY DATE i INSPECTION.7K �. DATE <br /> '1 E H 1426 Rev. 1-74 1-•74 2M :A+� <br />