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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 7 <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 the San. Joaquin Local Health District. <br /> ,� C. r F <br /> JOB ADDRESS/LOCATION S� � f'� �f /�Tf� CENSUS TRACT <br /> Owner's Name - �/lq1' Phone <br /> Address S 1 /yG .��7,y LaNECity /TReX-,*,0,q <br /> Contractor's Name 4 P1V4c!Jy S,F1o,� Pa C'd License V i Phone Z14- Z Y,50,3 <br /> TYPE OF WORK (Check) : NEW WELL.'/7 DEEPEN J7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR ' PUMP REPLACEMENT /7 C <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <: SEWER--LINES PIT PRIVY f <br /> SEWAGE DISPOSAL•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 ~w--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 _. &otary Type =of Grout ` <br /> k Disposal Other Other Information` ' ? <br /> i Geophysical Surface`S6aj Installed- By: ! <br />,PUMP INSTALLATION Contractor <br /> Type .of Pump H.P. <br /> P[TMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR; State Work Done ! D <br /> DESTRUCTION OF WELL: Well. Diameter _ -_--Approximate Depth <br /> Describe Material and kProcedue`�, <br /> I hereby agree- to-.comply-with all •laws- 'and -regurlations of-the -San-Joaquin-L—cal-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 Yiew .well I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify t8em 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I ., <br /> APPLICATION ACCEPTED,BY <br /> ADDIT.TONAL COMMENTDATE <br /> PHASE II GROUT INSPECTION - P FINAL 114SPECTION $ <br /> INSPECTION BY DATE INSPECTION BY DATE 3- <br /> 13 - R <br /> E H 1426 <br /> Rev. Y--74 LI75 2M _►� <br />