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- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT _ Permit No. � _ g1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-moi - <br /> (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 /> JOB ADDRESS/LOCATION, 4 , .✓ A-�n5U5 TRACT ' <br /> Owner's Name w Phone .36 F-1 .1 a <br /> Address City ' - <br /> Contractor's Name __ �. Z=e& Licensee , 373 Phone <br /> TYPE OF WORK (Check): NEW WELL.-/-7 DEEPEN /_7 -RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / /—PUMP 'REPAIR/ PUMP REPLACEMENT gr <br /> / <br /> i <br /> -Other / s <br /> DISTANCE TO NEAREST: SEPTIC TANK r 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 /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal I <br /> ,. Other .� Other Information . . <br /> Geophysical. #- Surface Seal Installed 'By: , <br /> PUMP INSTALLATION; • Contractor <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: State Work Done r J <br /> PUMP '.REPAIR <br /> ,.�,.�;:-�:,��•,�/ -State Work Done= <br /> DESTRUCTION OF WELL: <br /> We11. 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 neva 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 rue to- the,best .of my.�-knowledge and belief. I. WILL CALL FORA GROUT INSPECTION j <br /> PRIOR TO GROU G ' D A FIN INSPECTIO <br /> SIGNED a TITLE A <br /> RAW PLOT PLAN ON REVERSE SIDE 4 <br /> FOR DEPARTMENT USE ONLY.._ � <br /> PHASE I .. <br /> APPLICATION ACCEPTED BY 11 % DATE <br /> ADDITIONAL" :COMMENTS': �_ P <br /> PHASE II GROUT I SPECTION PHAS I.111UPAL INSPECTION <br /> INSPECTION BY ` _ DATE <br /> INSPECTION BY DAT -76 + <br /> E H 1426 Rev. 1-74 -- 9 U7,c1 9M <br />