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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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!'� r�lJ <br /> (Complete In Triplicate) zi <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct, `r <br /> and/or install the workPerein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and gulations: of the San Joaquin- Local Health District.: <br /> JOB ADDRESS/LOCATION J1 SAM C CENSUS TRACT : � <br /> Owner's Name Iy'Itk77ivj Z Phone <br /> Address '. . . City /�/ <br /> Contractor's Name License - Phone � + <br /> If i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN J / RECONDITION /_/ ' DESTRUCTION <br /> PUMP INSTM TION PUMP REPAIR / / PUMP REPLACEMENT_ <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELD 0?&( CSSPOOL/ EPAGE PIT OTHER <br /> PROPERTY LINEM PRIVATOMESTIC_ WELL_M& PUBLIC OMESTIC 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 Pif <br /> Domestic/public ' Driven Gauge of Casingeo <br /> Irrigation ' Gravel Pack Depth of Grout Seal Jed 4 <br /> F,} <br /> i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> I� r <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 4&- _ ' <br /> Describe Material aA&'o-cedure - '� <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 'fell"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 ofIlthe 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 FORA GROUT INSPECTION <br /> PRIOR TO G 0 TING r D A!� INAL ANSPECTION. `" �y ,�/ y 4.. <br /> SIGNED F TITLE 'e-35- <br /> -Ir-7 I WK^6AaW1WV <br /> I~ <br /> W PLOT :PLAN ON-REVERSE SID = <br /> ty <br /> F ARTMENT YSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I t�• DATE <br /> a <br /> ADDITIONAL COMMENT,,,: .F. <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY II DATE INSPECTION BY r DATE <br /> 077 _ 2M <br /> E H­1426 Rev. - 1-74 <br />