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N JOAQUIN LOCAL HEALTH DISTRIG uA <br /> FOPS OFFICE USE: , / 16�f E. Hazelton Ave. , Stockton, Ca1`_9 , <br /> V Telephone: (209) 466-6781, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1_27_i3 <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 �� AGc/�� % CENSUS TRACT <br /> a <br /> Owner's Name /p f /u /�cx�c� Phone Y!z 3 ZS-2- 247 <br /> Address City <br /> Contractor's Name _ s (// License # Phone 8 L2 <br /> �I�S <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN — RECONDITION /__7 DESTRUCTION /_ <br /> AL / <br /> PUMP INSTALLATION / 1PUMP REPAIR / / PUMP REPLACEMENT /Z7/ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY oV <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 /> Iomestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.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 t well and notify them before putting the well in use. The above <br /> information is true to a best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G FINAL INSPECTION. <br /> SIGNED rte, y �_ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I II � <br /> APPLICATION ACCEPTED BY - `f do cam— DATE -/- 2/- 7`5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DgTE - <br /> E A 1426 Rev. 1-74 _� , <br />