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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> BOE OFFICE USE: N" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -17dplr/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 77 <br /> (Complete In Triplicate) i <br /> Application is la.ereby 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 -7),1,V ESgo- �Ld7 C S T CT <br /> Owner's Name eit <br /> Address g,(� FV ru,� 1D e 1b re ?4 `Jp.IE �. ,7- City , <br /> /� I <br /> Contractor's Name (.':4_20-611 [,4�[ ,e� _ /�� ,a , License Phone <br /> f - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / kECONDITION / :/ DESTRUCTION /7 <br /> } PUMP INSTALLATION / / PUMP REPAIR �/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS!! y SEWER LINESSGD PIT PRIVY` <br /> SEWAGE DISPOSAL 'FIELD`'_-5W ICESSP00L/_SEEPAGE PIT R \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL; '��° { ,PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF .WELL CONSTRUCTION" SPECIFICATIONS / <br /> Industrial e-Cable Tool �wDia. of Well Excavation j- <br /> `t <br /> Domestic/private ' Drilled Dia. of Well Casing (r <br /> Domestic/public Driven Gauge of Casing t0 c <br /> Irrigation Gravel -Pack, Depth of Grout S!eal jTe m <br /> Cathodic Protection Rotary Type of Grout �✓ f' <br /> Disposal Other < Other Informatiog <br /> Geophysical Surface_ Seal_ Installed By:'/`�WI l-a- <br /> PUMP INSTALLATION: Contractor'k,L .. - <br /> a. Type of Pump S'r� - H.P. <br /> a ..._ <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: "M/ / 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 �reguLting 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 REPORV 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 GF.QUTING AND A EQAL INSPECTION. <br /> SIGNED TITLE <br /> D W:PL T PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -1-,7 <br /> 76 2M <br /> E H 1426 Rev. 1-74 � 3/ . <br />