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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. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued76 <br /> ~S700 S. (Complete In Triplicate) Cs_3v�p�p3 <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 <br /> County Ordinance No. 1 nd the Rules and Regula ons the an Joaquin Local Health District. <br /> i <br /> /�Q, <br /> JOB ADDRESS/LOCAT/11O/Nf F . � CENSUS TRACT <br /> Owner's Name /r �A)/�L 0,40 Phone ll/ <br /> G <br /> Address City <br /> Contractor's NameO%EX'9?9� /�U�� License Y?Aa3-5;?,5hone4 <br /> TYPE OF WORK (Check) NEW WELL/7 DEEPEN '/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION "/7 PUMP REPAIR .f PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY : o <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 i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 71 Other Other Information <br /> Geophysical Surface Seal Installed_My,:,, <br /> PUMP INSTALLATION: ' Contractor t <br /> Type .of Pump - . H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP":REPAIR• State-Work Don <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 E <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A f'INAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY _. 2r_ DATE �-,/!:Z,3:� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 i W75 2M_ <br />