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SAN JOAQUIN LOCAL HEALTH DISTRICT "r�� <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SCAN (,�O,l1 1 3 <br /> Telephone: (209) 466-6781 <br /> APPLIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <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. <br /> JOB ADDRESS/LOCATION ??� = CENSUS TRACT <br /> Owner's Name �y P �� s'� �� s Phone ;,1/ <br /> Address ., z 1S 7�?- -/_�4C i t 5 Th C Tt]D-J <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION //,,r PUMP REPAIR / / PUMP REPLACEMENT <br /> ,Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (,3 <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 /y", <br /> Domestic/private Drilled Dia, of Well Casing %i <br /> Domestic/public Driven Gauge of Casing iS <br /> Irrigation Gravel Pack Depth of Grout Seal s D �y- <br /> Cathodic Protection ." Rotary Type of Grout C�y,,Q <br /> Disposal Other Other Information <br /> —r— <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: r Contractor <br /> Type of Pump ��..� 3Q 6Zi/Z2 H.P. <br /> P MP 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GBQUTING AND A FINA I PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR JDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL CO TS: aly / �• � <br /> P S ' IIRO T SPECTI N -b/S <br /> P fi /�'TNAL INSPECTION--' <br /> INSPECTION BY TE "� - INSPECTION B)( ' ATE <br /> 53 /77 2M <br /> E H 1426 Rev. - 1-74 <br /> _ <br />