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u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. J <br /> Telephone: (209) 466-6781 !J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:? 1. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, ., - �i <br /> (Complete In Triplicate) l <br /> Application is hereby made to the San Joaquin Local Health District for s permit to construct 11 <br /> and/or install the work1herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San ;Joagain Local Health District:" <br /> JOB ADDRESS/LOCATION CENSUS TRACT , <br /> Owner's Name A 11' <br /> Phone ' <br /> �a !�� E <br /> Address l oaf �-a�L City <br /> Contractor's Nance 14,11 LCA, License # ajQQZZ 'Phone tIL6--OG9G <br /> .0 <br /> f. TYPE OF WORK (Check,): ANEW WELL ', DEEPEN '17 RECONDITION f_7 DESTRUCTION /7 I� <br /> _ PUMP INS,TALLE�TION /-7 PUMP REPAIR /� PUMP REPLACEMENT /7 j <br /> Other / — J <br /> DISTANCE TO NEAREST: SEPTIC TANK 'ji!5-o SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED U58: I: TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria. Cable Tool, Dia, of Well Excavation <br />{ « Domestic/private Drilled �� Dia. of Well Casing. a <br /> Domestic/public Driven ' �VwGauge -of Casing Cy J.b c) P V G <br /> _ Irrigation Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection Rotary , TypeY of Grout ...� <br />{ Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : j <br /> k PUMP INSTALLATION= ,� Contractor <br /> w. Type .of Pump f H.P. <br /> PUMP�REPLACEMENT; • •/ State Work Done <br />} PUMP REPAIR: /? State Work Done- <br /> DE&TRUCTI©N OF WELL: Well Diameter- �; Ap roximate Depth <br /> Describe,Material and Procedure <br /> I hereby agree to comply with all laws and 're-gulations:of�the`Sau Joaquin Local Ifealth District <br /> + and the State of Californiapertaining to or' regulating well' 'construction. Within FIFTEEN DAYS`. <br /> kafter completion of my 4ork on a new well, I will 'furnish the San Joaquin Local Health District`.a. <br /> WELL DRILLERS REPORT of JJ.the well- and notify them before putting..the..well. in.use.. The above I <br /> information is true to- the -best of my knowledge and belief.. I WILL CAL 'FOR'A GROUT INSPECTION J <br /> G PRIOR TO GROUTING 'AND .FINAL INSP CTION. <br /> SIGNED ' TITLE Y ~� <br /> DRAW_ PLOT PLAN ON REVERSE SIDE_..._, <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION' ACCEPTER,By DATE <br /> ADDITIONAL COMNENTS:`- 4 �J <br /> PHASE TI GROUT INSPECTION PHAS III/FISAL INSPECTION �J <br /> INSPECTION BY 11 DATE INSPECTION B - DATE -12-7L ! <br /> E'H'1426 Rev. 1-74', _ r" h/75 2M _ <br />