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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rW'OFFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A, 3S�S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4�/ <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 th San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> J°fjC r „� C. . �/ CENSUS TRACT C`7,7 10-2-9 <br /> Owner's Name f- Z)C-�V yq 1&0 Wjcc 5 Phone <br /> Address' Q J' eeii`l r 4w a&e City <br /> Contractor's Name , _ ��Z ;g.,, 7c Si�S GXl'oft/. License �� �1��_y3 Phone <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUA4P REPAIR /-7 PUMP REPLACEMEN 17 <br /> Other /% <br /> I i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD i 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 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven {- Gauge of Casing <br /> Irrigation Gravel Pack,,,, Depth of ,Grout Seal , <br /> '4 Cathodic'Pratection Rotary Type of Grout -� <br /> Disposal ' . Other Other Information - Q <br /> Geophysical Surface Seal Installed By: <br /> { PUMP INSTALLATION: Contractor " <br /> Type of Pump - 4N H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ir <br /> k PUMP REPAIR: /-7 State Work Done <br /> ,RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> P <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 i true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AOD AJSXU INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIewroE= <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �` DATE 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E III/F AL INSPECTIO <br /> INSPECTION BY DATE INSPECT I DATE - <br /> 5 I <br /> $ i E $ 1426 Rev. 1-74 1-74 2M <br />