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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1rOFFICE USE: A 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209)'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued &-f-7 <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 he San Joaquin Local Health District. <br /> (0 ? G►V6 o�fK �t) Long <br /> JOB ADDRESS/LOCATION p Can/( A4 lAt W e f= ZA1,2 f c �?dCENSUS TRACT <br /> Owner r s Name Phone i:(-y :Z:7-a5 <br /> Address <br /> City 1-7V*V -.,.. <br /> Contractor's Name MAILI #v 1 . ' Licensees d Phone .Zof <br /> TYPE OF WORK (Check): NEW WELL/R DEEPEN J-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /Z- PUMP REPAIR /% PUMP REPLACEMENT <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK If SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 17 0 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEa4 PRIVATE DOMESTIC WELL '_A;-=O PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation // V <br /> 4--Domestic/private Drilled Dia. of Well Casing <br /> Domestic./public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal {, <br /> Cathodic Protection 1�-= Rotary Type of Grout .0 A,' y <br /> Disposal , Other Other Information � —,,..,.Q <br /> Geophysical Surface Seal Installed By: ojgeeg . <br /> PUMP INSTALLATION: Contractorki 4Y _ <br /> Type of Pumprt s. %Lt� H.P. /Yz <br /> PUMP REPLACEMENT: / / State Work Done <br /> r• <br /> PUMP:REPAIR: /? State Work Done <br /> ES-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 wel.l, .I will furnish the San Joaquin Local Health District <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 <br /> (DRAW PLOT PLAN ON REVERSE SIDEPF <br /> �✓H'D�s/HJ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �Q ! DATE /�- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE =FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />