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_kf SAN JOAQUIN LOCAL HEALTH DISTRT^T <br /> F01 OFFICE USE: 1 E. Hazelton Ave. , Stockton, �..-Lif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> !Application is hereby made to the San Joaquin Local Ilealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��7 ��/jar�ryj� �— Lj C CENSUS TRACT <br /> Owner's Name 4L ����CJ'Cru Phone 1147-1-1 <br /> Address ,� I� City <br /> Contractor's Name C d eZ, ( r�'� _ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / " DEEPEN /_% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INST LATION / ,/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other P % <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER - NES = — PIT PRIVY <br /> SEWAGE DISPOSA�LIELD� CESSPOOL/SEEPAGE PIT OTHER -- <br /> PROPERTY LINE W PRIVATE MESTIC 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 <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: �G'h <br /> PUMP INSTALLATION: Contractor <br /> n <br /> Type of Pump C Uzz; H.P. <br /> a <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 <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 y knowledge and belief. I WILL CALL FOR A GROUT ,INSPECTIPV <br /> PRIOR TO GROUTING D A FINAL INS CTION. <br /> SIGNED 4c- << u TITLE y <br /> (DRAW PLOT PLAN ON REVERSE SIDW_ 4j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C: <br /> DATE <br /> ADDITIONAL COMMENTS: e401' allllC72& <br /> PHASE II ROUT INSP ION fPHASE II INAL INSPECTIO <br /> INSPECTION BY DAT / __INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1./7c 9M <br />