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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: /0/w 1601 E. Haze'.ton-kve. , 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 g <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. 18622 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( .�2 4 G CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name U&License # 0,?/ Phone i-52?103J <br /> QJA <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION gyp/ <br /> PUMP INSTALLATION ./ / 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO S <br /> Industrial Cable Tool Dia, of Well Excavation \ <br /> L-'bomestic/private z---Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - " <br /> Cathodic Protection Z_—Rotary Type of Grout \ t <br /> Disposal Other Other Information V <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: // State Work Done <br /> DES-TRU TION OF WELL Wel Diameter pAppate Depth <br /> Describe Material and Procedure <br /> (��,o� /a- Cyd ,T �.✓��r� 4 r/2 0 �-�-, �r <br /> I hereby agree to complytwith 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-new­we�ll-;^I" i"l`7"" u�n�he an oaquin ocal.. Realth 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 GPOUTING AND F AL INS CTION. en <br /> SIGNED /L ) TITLE <br /> Vi D T F% ON REV' SE SIDE) '711,!: <br /> OR DEPARTMENT USE ONLY / <br /> PHASE I / / 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE IN NSPECTION <br /> INSPECTION BY DATE /d2_/_7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />