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SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> 0— OPFICE USE: V 1601 E. Hazelton Ave. , Stockton. Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /c/-2� <br /> I (Complete 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 the San Joaquin Local Health District. <br /> ;TOB ADDRESS/LOCATION 1v L es/ CENSUS TRACT <br /> f <br /> Owner's Name ��- 'K } i J``?�- / Phone <br /> Address ��f ✓ lu4 ;1'�� '� � Cit <br /> rkj <br /> 11 � <br /> !Contractor's Name e1 `T� U�J Licensel���R�Phone4tgd�� ^ <br /> TYPE OF WORK (Check): NEW WELL-/-7 DEEPEN /? RECONDITION 1-7 DESTRUCTION f7 <br /> PUMP INSTALLATION El PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other L-1 <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 f Cable Tool Dia. of Well Excavation w <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation .! Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection + Rotary Type of Grout <br /> Disposal , I Other. Other Information r <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor H.P. <br /> Type of Pump d� <br /> 1ZA <br /> PUMP REPLACEMENT: State Work Done' <br /> PUMP-,tREPAIR-s, - / ". .State-Work Done <br /> „PESTdRUCTION 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. <br /> SIGNED TITLE 2Z <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _LF—Z <br /> ADDITIONAL COMMENTS: <br /> ;PHASE II GROUT INSPECTION PHASE III FINAL' NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3G <br /> 40 <br /> E H 1426 Rev. 1-74 1-74 2M <br />