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V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,;OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6-/"LM <br /> THIS PERMIT "EXPIRES I YEAR FROM DATE ISSUED Date Issued 4-a-7e' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> tand/or install the work herein described. This application is made in compliance with .San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATIO'NN Q10 23 �/ /!, �Oo. �,�OO,Q��� CENSUS TRACT <br /> Owner's Name '_ �A .7o-CA1.ir ( o' Phone ' <br /> ' Address ��7 , city zt <br /> Contractor's Name ,���}�2.- _ License # ' L7 G'Gz Phone 'V'z <br /> ' TYPE OF WORK (Check)- NEW WELL DEEPEN /7 RECONDITION L7 DESTRUCTION (7 <br /> PUMP INSTALLATION L_7 PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> ' Other L_1 <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool - Dia: of Well Excavation 117 <br /> ' ==Domestic/private Drilled Dia. of Well Casing 1. <br /> Domestic/public Driven - Gauge of Casing 12 \� <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection Rotary -_ „Type of Grouts <br /> Disposal Other Other Information" <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / . State Work Done <br /> I PU4 tIiPAIR:f / / State Work Done l T <br /> rPESTRUCTION OF WELL, Well Diameter Approximate Depth <br /> { Describe Material and Procedure <br /> 'I 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 TOG I 1 I ECT ION. <br /> t! SIGNED — TITLE <br /> T (DRAW PLOT PLAN ON REVERSE SIDE_:.. .. <br /> FO DEPARTMENT USE ONLY <br /> j PHASE I - <br /> ' lAPPLICATION ACCEPTED BY DATE <br /> I ADDITIONAL COMMENTS: <br /> P E GROUT INSPECTION PHA IT FINAL INSPECTION <br /> ' ' INSPECTION BYy� - DATE '. 6 INSPECTION BY DATE <br /> s <br /> E H. 1426 Rev. 1-74 hL25. .2M <br />