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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEr_OFFICE USE: 1601 E. Hazelton-Ave.-; 'Stockton, Calif. i <br /> Telephone.- - (209) 466-6'781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 'a - i+c•jC,4 4a r?.j <br /> THIS PERMIT EXPIRES 1 YEARfFROM ,DATE ISSUED Date Issued <br /> ,..(Complete: InJriplicate) <br /> Application is herebyimade to- the 'Sari 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 Regulat ons,sof:,.the: San Joaquin Local health District. <br /> JOB ADDRESS/.LOCATION OF0.58`5 , G CENSUS TRACT <br /> Owner's Name , :.,, `f �g y,, �� Phone <br /> Address=� Wvsi=G.� --. Y.,.. •.� City 0lbC&76--_J <br /> Contractors Name,�,9. 5 yvt .,� �„ �^". License #RL9.o Phone <br /> TYPE OF WORK (Check): NEW—WELL.'/-7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR . PUMP REPLACEMENT f7 f <br /> Other V/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD E CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WEi:L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool `' Dia. of Well Exdavation <br /> ".Domestic/private Drilled -Dia. tof'Well Casing <br /> Domestic/public Driven Gauge. of Casing` <br /> Irrigation Gravel Pack Depth of Grout¢Seal <br /> 'Cathodic Protect on Rotary Type-4of Grout <br /> Disposal Other 0.ther. Information r <br /> Geo-phyeicalT..- Surface Seal Installed By: <br /> PUMP INSTALLATION:, Contractor <br /> y_ Type of Pump s H``;P. <br /> ^f <br /> PUMP REPLACEMENT: <br /> L State Work Done - z. .• �, a' y- <br /> PUMI'''.REPAIR:�" �, ..-.State'"Woitk"Done" <br /> PES�TRUCTION OF WELL: Well Diameter €.r 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 re$`ulating 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 -be'lief. I 'WILL' CALL FOR-A 'GROUT INSPECTION <br /> PRIOR TO GROUTINfihAND A FI 1INSPECTION, <br /> SIGNED _ TITLE <br /> 3 .,e CD PLOT PLAN ON -REVERSE' SIDE +: <br /> /. OR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G Tt XSPEVf0N PHASE III FINAL INSPECTION. . <br /> INSPECTION BY 'DATE -INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M-,� <br />