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r <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;-1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2Y7-1IFO--0% <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 ,Rales and Regulationsf kLee p Joaq)in�Local Heal District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT �j <br /> Owner's Name '' R f (., 4� 1�1 J fPhone _ /�l�iL <br /> Address City C*3ZOAl <br /> Contractor's Name �, 7.�y7TQ, �I-�t7 Al License #��? Phone 5? -6Qo7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP. INSTALL.ATION PUMP REPAIR /-7 7FUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT. 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 /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed By:- <br /> PUMP <br /> y _PUMP INSTALLATION: , Contractor _ Q A) <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done _ <br /> a&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 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 JOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A NAL INSPECTION. <br /> SIGNEDTITLS _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FQR/AEPARTMV9T USE ONLY <br /> PHASE I // <br /> APPLICATION ACCEPT j��LI/v4T/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAV II INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION ABY DATE <br /> Aw <br /> t E H 1426 Rev. 1-74 1-74 2M <br />