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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -� q 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) l �7--0,1,0-�-AO2 <br /> Application is hereby madelto.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. <br /> JOB ADDRESS/LOCATION 11/Q{ p, , CENSUS TRACT~ <br /> Owner's Name Phone . 4 '77-M /4'?ci` <br /> ii <br /> Address Cit <br /> Contractor's'Name zz 4E, License # /G ''Phone `fO�- 24 <br /> TYPE OF WORK (Check): NEW' WELL:-L_-_7 DEEPEN -/7 RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /)� PUMP REPLACEMENT /7 fi <br /> Other / / � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER m <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE .) 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial 14 + Cable Tool Dia. of Well Excavation <br /> Domestic/private 1i 1 Drilled Dia. of Well Casing <br /> >Domestic/public k + 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: <br /> PUMP INSTALLATION: Contractor Q I v <br /> a <br /> 1 Type of Pump 6 H.P. 7� <br /> I <br /> PUMP REPLACEMENT: /—/ . :State Work Done <br /> ' If <br /> PUMP !REPAIR: <br /> /�('(TI�� State Work Done _ <br /> i <br /> ip I <br /> ,?ES;TRUCTION 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 ori a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use.. The above <br /> information is true to the!�best-otmy mowledge belief. I WILL CALL FOA A -GROUT INSPECTION i <br /> PRIOR TO GROUPING AND A FINAL INSP 0 k <br /> SIGNEDfLE <br /> (DRAW PLOT PLAN ON SIL_ <br /> V RSE SI <br /> p <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE ,12,-7 <br /> [� <br /> ADDITIONAL COMMENTS: �MT <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECT ON f <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> wT1 E H 1426 Rev. 1.-74 1-74 2M <br />