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J / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�3- Tom ! <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name /YlA/��/ /1�1.,/� �L.. <br /> Phone <br /> Address . .Y <br /> City <br /> Contractor's Name r. /1'1A"_022 0 License # Ls97 Phone Y11 14/x. <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN RECONDITION /? DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION =�` PUMP REPAIR /7 PUMP REPLACEMENT 17Other /J —~ <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 SEWER LINES /tea 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 116 <br /> ::7�_ omeatic/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 C <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .c4 ~ <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 knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br />'SIGNED ..r TITLE .a <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I �-- <br /> APPLICATION ACCEPTED BY DATE 7 S <br /> ADDITIONAL CO -- <br /> MMENTS: <br /> P SE I GROUT INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 7 <br /> i <br /> 5.. <br /> t E H 1426 Rev. 1-74 1-7� <br />