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FO& OFFICE USE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In <br /> Application is hereby made to the San Joaquin Local rHealth tDistrict for a permit to construct I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 anan Joaquin Local Health <br /> d the Rules and Regulations of the SDistrict. . <br /> `(7' Cvf/aJ 4 '(20: <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT 7-0-6-P3?o•-y0 <br /> Owner's Name GM,b Q, L iCnn - <br /> Phone _UL— <br /> 766-3 <br /> Address _ - ! b�..s� '1 C°„ _t7 N9 <br /> City , <br /> Contractor's Name � ��Suyd <br /> License # ,Phone <br /> TYPE OF WORK (Check): NEW WELL,/ T DEEPEN RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/-7 PUMP REPAIR/_7PUMP REPLACEMENT / <br /> Other ET .. <br /> _ <br /> DISTANCE TO NEAREST: ; SEPTIC TANK iSEWER LINES G PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DO OD i <br /> INTENDED USE WELL CMESTIC WELL PUBLIC DOMESTIC WELL <br /> µ TYPE�F ONSTRUCTION SPECIFICATIONS <br /> Industrial V Cable Tool Dia. of Well Excavation J <br /> _ Domestic/private — 1- Drilled ._-_Dia. <br /> _ . <br /> Domestic/public - Dia. 'of Well Casing E <br /> Irrigation Drive-n'_.._ : Gauge zof Casing ( ld e <br /> Cathodic Protection <br /> Gravel Pack .'___Depth of Grout Seal f i <br /> Rotary =' Type of Grout <br /> Disposal Other Other Information. <br /> Surface Seal Installed B <br /> PUMP INSTALLATION Contractor_ <br /> Type_of-pomp: <br /> _ ._ _ - H.-P.- <br /> PUMP REPLACEMENT: <br /> L/ -State Work Done <br /> PUMP�REP_AIR: p <br /> _State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter N �� <br /> Describe Material and Procedure Approximate Depth <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 the well and notify them before putting the well in use. The above <br /> information is true to-the"bestof" my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> ' TITLE <br /> w+re+w rLu1 PLAN ON REVERSE SIDE <br /> PHASE IDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �, L <br /> AD TIONAL COMMENTS: DATE Z( <br /> PHASE I- <br /> i BY GROUT INSPECTION P I NAL IN--- <br /> IDATE INSPECTION B <br /> ------- "' � DATE •.ao <br /> E H 1426 Rev. 1-74 / f <br /> ~ h/7r] 2M <br />