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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOL OFFICE USE: 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 <br /> Q (0 ? IJ "17`146r-_fo, ,e id' (Complete In Triplicate) A PIJ ; 003-moo-1 C- <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. 862 and the Rules and Regulations of the San Joaquin Loc 1 Health District. <br /> LN ` s <br /> JOB ADDRESS/LOCATI + ®�24''�CENSUS TRACT ' <br /> Owner's Name +_ _ pPhone � '� <br /> —.�., - <br /> Address �1 LyL - <br /> Contractor's Name L�/' U' '% 3 License hone4 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-T DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / Lv <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 4` <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7W <br /> Type of Pump TH.P. `� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: J / State Work Done <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 <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 FINAL INSPECTION. �YY" <br /> SIGNED 6,J �,,< 7 r` v1�'^ _ _ _ TITLE <br /> '(DRAW <br /> `PT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .�:I. f DATE ZS-7-7I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (°� dj DATE <br /> �'��""�.-✓, ,, � ,, - <br /> E H 1426 Rev. 1-74 3/76 . 2M <br />