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/ �AN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: Y 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 LLZ-Z1 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Wil Tia <br /> ' Phone 428=1 512 <br /> 1,�Itonktnn. -Ca <br /> I Address 6851 N. -Eildreth T.alieCity <br /> i <br /> License � 0�7c�Q Phone - <br /> Contractor s Name <br /> ` 1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /-7 bESTRUCTION /- <br /> PUMP] INSTALLATION/ / PUMP REPAIR ]bL/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELll CESSPOOL/SEEPAGE PIT OTHER • -,' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ITYPE 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' l <br /> Geophysical ! Surface Seal Installed B <br /> 4 PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP .REPAIR: / / M1 State Work Done <br /> t DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> F and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> l after completion of my work on a new well, I will furnish the San Joaquin Local Health District F <br /> f 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLC3T PLAN 'ON RE FRSE SIDE) <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 37 <br /> E H 1426 Rev. 1-74 ���� <br />