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Lli67SAN JOAQUIN. LOCAL HEALTH DISTRICT 1 <br /> FOR+OFFICE USE: y 1601 E. Hazelton Ave. ,' Stockton, Calif.` ! <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) . <br /> Application is hereby made tol,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 /> JOB ADDRESS/LOCATION—l 16 q`/Z G CENSUS TRACT <br /> Own'er's Name I L AO yj <br /> /� �� .� Phone <br /> Address ___l1a I? _3 E ' �s.k] f P? f o�J' r : City F5C i:3 L. e,li <br /> Contractor's Name _� (�. y�7{p cr Sc nJ License !� 7%OlPhone 9.9' x07` <br /> ' t <br /> TYPE OF WORK (Check). NEW WELL /—j DEEPEN / % RECONDITION /-j DESTRUCTION /7 <br /> t/PUMP INSTALLATION /% PUMP REPAIR PUMP REPLAC T' /_7 <br /> Otherzi <br /> DISTANCE TO NEAREST: :;SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <OTHER � I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL-- <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool ` Dia. of _Well Excavation, I <br /> Domestic/private, i Drilled Dia. of Well Casing > <br /> Domestic/public f Driven Gauge of- Casing <br /> Irrigation Gravel Pack _6epth of Grout Seal <br /> Cathodic Protection I Rotary '- Type of Grout f <br /> Disposal Other__ __Other_1nformation, <br /> Geophys __ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Q)- <br /> __�y d <br /> PUMP REPLACEMENT: /% State Work Done <br /> -'PUMP 'BEPAZR:�`-�•..•---,� - �- —� <br /> �' Sl ate Work Done <br /> pE5•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 construction. ( Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districtia <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in-use.. The above ! <br /> information is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND FININSPECTION. < r <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEEPARTMENT USE ONLY <br /> PHASE I /j // <br /> APPLICATION ACCEPTED BY `� `'7�06(/ 4� DATE <br /> ADDITIONAL COMMENTS: t sem^ <br /> PHASE II GROUT INSPECTION PHAS , II' F INSPECTION <br /> 41SPECTZON BY DATE INSPECTION BYG/ y DATE " jf�5 t <br /> �i E H 1426 Rev. 1-74 1-74 2M , <br />