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f SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOH OFFICE USE:. I'd 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7S Src� <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED: Date Issued .Z -22 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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. 4, <br /> County Ordinance No. 1862 and the Rules and Regulations of t San Joaquin Local Health District. I <br /> 1 /SV T <br /> JOB ADDRESS/LOCATION SUS TRACTa,,CV <br /> 4 <br /> Phone <br /> Owner's Name /�L <br /> Address I1�J�! LQ, City <br /> Contractor's Name License # ,25A?77Phone /4&P- <br /> y <br /> TYPE OF WORK (Check),:, NEW WELL DEEP / / RECONDITION / / DESTRUCTION /� 1 <br /> 'PUMP INSTALLATION & PUMP REPAIR/ / PUMP REPLACEMENT /7 \ <br /> Other <br /> r <br /> .DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY �I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` h <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 f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing <br /> Gravel Pac Depth of Grout Seal <br /> Cathodic Protection • Rotary Type of Grout <br /> Disposal t Other Other Information ' <br /> Geophysical <br /> Surface Seal Installed By: <br /> - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / : State Work Done <br /> PUMP .REPAIR: / / ' State Work�Done'° <br /> L-/> �L-4 — I< ��- w /✓v � c.. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater- al-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 est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJ49bG AND A M,6r, INSPECT N. <br /> SIGNED TITLE G(J/t.Gf' <br /> DRAW <br /> PLOT PLAN 'ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE _ /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �Sq <br /> �r�5 � �" ,� �^ �x 7/77 <br /> . qq <br /> E H 1426 Rev. o����i�a1 ,� �rP <br />