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J�/'/� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$%OFFICE USE: v 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 Date Issued <br /> `l (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> d 2VI 4 , H14 ► a D CENSUS TRACT <br /> Owner's Name Fr2 IA A/Cl e tl c,l /q 2 0Phone <br /> Address /l ��±7 .� �f9 C1Ci/j , �J ��i City <br /> Contractor's Name LS-,/k , License #1 27.90yphone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP IN�S�TALLATION /X/ POMP REPAIR /7 PUMP REPLACEMENT /7 <br /> 0ther". "To 4,e <br /> i <br /> DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES PIT PRIVY <br /> j SEWAGi 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 P- 4 Cable Tool ��Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public = Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 191 Cathodic Protection Rotary Type of `Grout <br /> Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: <br /> !I PUMP INSTALLATION: Contractor <br /> I - <br /> Type,.'of Pump T H.P. <br /> PUMP REPLACEMENT: / // Sork Done 1 u <br /> PUMP iREPAIA: /7 State Work Done _ <br /> i f <br /> TRUCTION OF WELL: Well Diameter Approximate Depth \ <br /> Describe Material and Procedure <br /> f I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining to or regulating_well,construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; I will-furnishIthe 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 G UTING AND kFIN INSPECTION. <br /> SIGNED I TITLEfE11A <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> R DEP MENT USE ONLY <br /> PHASE I q <br /> APPLICATION ACCEPTE AUNOT( DATE / 'Z/• 7,6 <br /> ADDITIONAL COMMENTS: ) <br /> � "PHASE II GROUT INSPECTION PHASE II P •NAL INSPECTIO <br /> * <br /> SPECTION BY )DATE INSPECTION BY "i ➢ATE _ � <br /> E H 1426 Rev:' 1-74 "'`I 1-74 2M <br />