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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 7 11;5-ljp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued cf A-77 <br /> o (Complete In Triplicate) <br /> Application s 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 g tz) /� ?dl�a/CENSUS TRACT (ALJ.-1 qv—v2. <br /> Owner's Name % j�B.yyt sOn B Phone <br /> Address a , e a16 01 <br /> City <br /> Contractor's Name License # /� i,j Phone v . <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN / RECONDITION /__/ DESTRUCTION /- <br /> AL _ <br /> PUMP INSTLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT <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 p <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 /> Irrigation Gravel Pack Depth of Grout Seal. <br /> CathodicProtection Rotary Type of Grout <br /> Disposal Other Other Information a <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C . <br /> Type of Pump =af. I?G H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -Rf2A-1-R: <br /> / State Work Done <br /> DESTRUCTION 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 �y'��knowledge,a d belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPEyCTION <br /> SIGNED TLE �►� <br /> ( _'LO PLAN ON R RSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY )0�6zjl, DATE <br /> ADDITIONAL COMMENTS: - -- <br /> PHASE II GROUT INSPECTION PH9SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 41C." DATE —J <br /> E H 1426 Rev. - l-74 n!%7 2M <br />