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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAiOFFICE USE: 1601 E. Hazelton <br /> Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 711--_VSp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Comp�e.te_ 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 t} San J a uin LocaHealth District. <br /> JOB ADDRESS/LOCATION q -- __ndo CENSUS TRACT <br /> Owner's Name L L s Phone <br /> Address 4z 1�! d! city �•�cF. <br /> Contractor's Name �0 License #c>,9;79V10 Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /? RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION L_1 PUMP REPAIR � PUMP REPLACEMENT J <br /> Other 4'.) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> • �r I <br /> PUMP-:REPAIR: �r�I State -Work Done -,Q Eip r- <br /> v�" ,I <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth i <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 <br /> 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 CALLFOR A GROUT INSPECTION <br /> PRIOR TO GROUT1jtLG AND A FMkL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4/7 ?" , <br /> APPLICATION ACCEPTED BY DATE �J T' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASAl-2-FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE lr Ifr_gs <br /> 2 H 1426 Rev. 1-74 1-74 2M <br />