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. : f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR. FROM DATE ISSUED Date Issued �77 <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 hereindescribed. 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 5&o-rT / Phone AI77' yez 9 <br /> y <br /> Address 7 � � City S ! �l� tU X26. <br /> f r <br /> Contractor's Name LARK VjfLL _n G Ut�1 �A1T CoC0 License # 6kO.Z, Phone <br /> TYPE OF WORD (Check) : NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION ./JT <br /> f PUMP INSTALLATION / / PUMP REPAIR / -/ PUMP REPLACEMENT /7 <br /> - - 0then <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 1� PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE '- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> -INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _:�endustrial Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven ' Gauge 'of Casing -At <br /> Irrigation ravel Pack Depth of Grout Seal Q <br /> Cathodic Protection ZeRotary Type of Grout -� <br /> Disposal _ Other Other Information <br /> Geophi sical ' Surface Seal Installed By: <br /> PUMP INSTALLATION:,_--',Contractor <br /> Type �o�f.�Pump H.P. <br /> P <br /> PUMP REPLACEMENT: / / State Work Done l <br /> PUMP .REPAIR: / / * State Work Done <br /> .# cs <br /> i. DESTRUCTION OF WELL: Welf 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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the .well and notify them before putting thewell in use.. The above <br />'. information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI N <br />' PRIOR TO GROUTIN AND A FINAL SPECTI N.a <br /> SIGNED TITLE ( VI4! I? _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> Aui_ FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> APPLICATION ACCEPTED 'BY y DATE IC-�. '_Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br />{ INSPECTION BY DATE INSPECTION BY DATE <br /> l E H 1426 Rev. - I-74 -.p - _ - -- <br />