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.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> oXtOFFICE USE: '.. ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,,,-1�_? V <br /> 7s�S3az A0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) S <br /> Application is hereby made to the San Joaquin Local Health District far ae �to c cons�ruct <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin ` <br /> County Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin Local Health District. <br /> AB Ai?DRESS/LOCATION &;V15 a& A AK Lee(4/ 1!- CENSUS TRACT � <br /> Owner's Name � ��� ��� -� --- -- Phone <br /> Address o ,ems �: `11_ City <br /> icense 9JZJ< ' hone. /J, ► . <br /> Contractor's Name <br /> j TYPE OF WORK (Check): NEW WELL /#----DEEP EN /_7'-RECONDITION /7 DESTRUCTION /f <br /> PUMP INSTALLATION /'PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> ' <br /> Other <br /> � I <br /> l DISTANCE TO NEAREST: SEPTIC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,s <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC .DOMESTIC WELL <br /> INTENDED USE TYPE OE WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialyUable Tool Dia. of Well Excavation <br /> --i,. Drilled R Dia. of Well Casing <br /> f Domestic/public Driven ,Y Gauge of Casing - <br /> ,` Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout q 1#1 - <br /> I Disposal Other Other Information <br /> .,-_.1 Geophysical Surface Seal Installed B <br /> t PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: -State. Work-Done - - - - - <br /> ES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> IEhereby 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 puttingthe-.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 D A FINAL IN ION. <br /> [ SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> � PTiASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE TTI/F AL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE Jb <br /> i R ~E H 1426 Rev. 1--74 1-74 2M <br />