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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF OFFICE USE: 16 Hazelton Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466--6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> } <br /> THISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. �y'7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or. i,nstall 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 _._ 21131 L6m a^J CENSUS: TRACT <br /> Owner's Name �� F j�[,.�,� Phone <br /> Address LE"4,0 �,6 City <br /> Contractor's Name S�` ,,,t G I7�STc License # A VI o3irhone 5-a---fd Z 7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ J RECONDITION / J DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / J <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 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ►`\' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Y _ <br /> Domestic/public Driven Gauge of Casing f , <br /> Irrigation Gravel Pack Depth of Grout Seal "L <br /> Cathodic Protection T� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ QW106k <br /> k <br /> PUMP INSTALLATION: Contractor,. y_STAN t LAV S <br /> Type of Pump / H.P. [� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State W6rk Done <br />' DES•TRUCTION 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'constructi.on. 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 <br /> T (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ( `] <br /> APPLICATION ACCEPTED BY V`J DATE � � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FIN INSPECTI N <br /> INSPECTION BY DATE /✓ INSPECTION B DATE 'I <br /> E H 1426 Rev. '- 1-74 b/77 M <br />