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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH,OFFICE USE: 1601 E. Hazelton Ave. , ' Stockton, Calif. <br /> 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 _s--1f-,> <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal: 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 /> JOE ADDRESS/LOCATION f 01,5 /4 t N 2 pic + CENSUS TRACT <br /> Owne r l s Name 1 Phone "o2 73 <br /> Address , <br /> city C A)-rxL <br /> Contractor's Name -�� „) License C2/25 0/y Phone 93R aW. <br /> TYPE OF WORK (Check); NEW WELL -/7 DEEPEN/? RECONDITIONL7 DESTRUCTION /w]` <br /> PUMP .INSTALLATION '/3q PUMP REPAIR -/_7 MP PUREPLAC�NT /7 <br /> .-. u Other /t E t--AIL,D <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> `.' SEWAGEDISPOSAL FIELD 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical - `'Surface Seal Installed 'By: <br /> PUMP INSTALLATION: 'Contractor �•j��p,.,.��`^ J� <br /> ,---Type-•.of.!-Pump - � .,r _•. . H.P. <br /> PUMP REPLACEMENT: %// State Work Done ; <br />.PUMP ,.REPAIR; /7 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 j <br /> WELL DRILLERS REPORT�of the -well and notify them before putting- the..'Well ,in use.. . The above I <br />.information is true to the-besti.of. my..knowledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING D FINAL INSPECTION: <br />'SIGNED TITLE - <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> PHASE I R TMENT U ONLY <br /> APPLICATION.-AC [fA L111IO`f-� DATE , <br /> ADDITIONAL COMMENTS: <br /> -„ PHASE II GROUT INSPECTION - PHA'S&II INAL INSPECTI <br /> INSPECTION BY _ DATE INSPECTIONBY DATE <br /> e <br /> E H 1426 Rav_ 1_74 <br />