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__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OrVICE USE: lE E. Hazelton Ave. , Stockton, C. f. <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 Issue d7--/6.-2 7 <br /> (Complete In Triplicate) i <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�/ P ���ie./ 52 - CENSUS TRACT <br /> Owner's Name Phone es P-- :2 !9e <br /> Address — t fit" -1 F7 S�• . e'�.J e� f� / _ City c <br /> Contractor's Name TPhone, -2 �%X7.1 <br /> n i�� Jn�Ry tit r-ASOV <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f ZS— SEWER LINES 1 't y-- PIT PRIVY - <br /> SEWAGE 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 _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing !h 40 <br /> Irrigation x Gravel Pack Depth of Grout Seal ,sp FI' <br /> Cathodic Protection _X Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B 2t <br /> PUMP INSTALLATION: Contractor ',.. <br /> Type of Pump L-d H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 011, <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 best of my owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE N. <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> el- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -7DATE gyp/ <br /> ADDITIONAL COMMENTS: <br /> PHASEGROUT INSPECTION P SE M- INAL,,I;NSPECTION <br /> INSPECTION BY -—INSPECT-1 y <br /> E H 1426 Rev. - 1-74 <br />