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O£� _ dSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F :OFFICE USE: 1601 E. Hazelton`Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7��19� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In•Triplicate) <br /> AppliceFtion is her6byymade 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 Joa uin Local Health District. <br /> JOB ADDRESS/LOCATION �, , G CENSUS TRACT 18'7 -4-5'0 0 ! <br /> Owner's Name (D,6_°k_tj Phone <br /> Address g F. (� Cit <br /> Contractor's Name Y 3 4 G <br /> License # � ,�c Phone ,ti�� - <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN '/? RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /-/ PUMP REPAIR -/-7-PUMP REPLACEMENT �f <br /> Other /_7 <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 i Cable. Too1 Dia. of Well Excavation <br /> Domestic/private ` Drilleii '--Dia•._ of Well Casing <br /> Domestic/public Driven Giuge of Casing /4_-V2 L� <br /> Irrigation ' Pack Depth .of Grout Seal <br /> Cathodic Protection Rotary Type-of- Grout <br /> Disposal Other �- Other Information <br /> Geoph sical Surface Seal Installed BY: wez t�} <br /> Ak <br /> PUMP INSTALLATION: Contractor ;,� 4 � uj� u4 LLC�,� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT J / State Work bone <br /> PUMP '.REPAIR: State Work Done Y <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 my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��rG <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J/ .y f •7 <br /> E H 1426 Rev.-I-74 f` <br />