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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE USE: 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 /> ' , (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 Joaquii <br /> County Ordinance No. 1862 an' d the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 'I ��� { �/' �/' <br /> rfCs i`Ca-� CENSUS TRACT <br /> Owner's Name �}/a'!6!�J'/ S�h /' Phone _Jam',/�/—�3�,3L <br /> Address /'�/�/ ,`�.� ,2G - T City STG��� _ <br /> Contractor's Name License #,ZwPhone 2'. <br /> 1 <br /> Ze <br /> TYPE OF WORK (Check) : NEW,WELL /J DEEPEN /_% RECONDITION,/—DES-T-RUCTION_/ <br /> PUMP, INSTALLATION Jl7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, OTHER <br /> PROPERTY LINEI6* 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 L! q <br /> T Domestic/public Driven '.. Gauge of Casing /1 <br /> Irrigation Gravel Pack `* Depth of Grout Seal <br /> Cathodic Protection Rotary •Type of Grout o_�•. ,_ 1 <br /> 1. Disposal -OtheY Othei Information'- <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' Li�--s �/ � I <br /> Type of Pump �a''l6yr�Prrl e H.P. <br /> PUMP REPLACEMENT: / / State lWo-rk-Dbne - — <br /> PUMP .REPAIR: / / _ State Work Done �- <br /> i � <br /> DESTRUCTION OF WELL: Well Piameter i i"-" - Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all ,laws and regulations of the San Joaquin Locall Health District <br /> and the State of Calif ornialpertaining to or regulating well construction. Within FIFTEEN DA`�.S <br /> . after comp le tion ,of my work� on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT jwell and notify them before putting the well in use. The above <br /> information is tru to the best o my knowledge and belief. I WILL CALL FOR AGROUT INSPECTION <br /> PRIOR TO 6 -F-i IbWECTION. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE // -1747 <br /> ADDITIONAL COMMENTS• . 1 - <br /> PUTT INSPECTION ; . PHASE III/FINAL INSPECTION <br /> INSPECTION BY ! I DATE INSPECTION BY /a DATE 3 " .3/ '7 <br /> E H 1426Rev. f-74 ' 1177 2M <br />