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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> e Q i <br /> FO09.©FFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5'3j1/Q' <br /> THIS PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) lel-- 0-70-0e <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 /> ' <br /> 705"7- S <br /> JOB ADDRESS/LOCATION _ T r r 4 -. y ;,- , tlll CENSUS TRACT <br /> Owner's Name , , E• ,,c« ., r : e_f/ f_t ._ I�, Phone <br /> Address --- 3 - =` -# --- - _ City j - , <br /> Contractor's Name �-*_ �3 ,M., l p �_• License # d�,� (Fhone <br /> TYPE OF WORK (Check'): NEW WELL /� DEEPEN /� 'RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR // PUMP REPLACEMENT /-7 <br /> Other <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 /> r Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <_ r" _ ►�, _.� ""..., . '"r <br /> Type of Pump _ ^^� �i, i _ " H.P. V-e- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: L7 State Work Done <br /> ,AES•TRUCTION 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 C.` ,,,lf ' 1 ,, _ TITLE <br /> A A DRAW�PLOT PLAN ON REQ SE SIDE <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYX4DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />