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!# QSAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FORrOFFICE USE: V/ 1601 E. Hazelton Ave. , Stockton, Calif._ <br /> r 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 # <br /> (CompleteIn Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'and/or install the wort 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 Zw&21 CENSUS TRACT X. <br /> 0 . <br /> Owner's Name y`--.L1h� I. ..,. , ,., Phone 16 —7 Sal <br /> n - -- <br /> Address - -- ---- `�`: �. S��0]� rPZZ- - -Citq <br /> Contractor's NameLicense # <br /> y Phone n? � <br /> TYPE OF WORK (Check): NEW WELL DEEPENRECONDITION /7 DESTRUCTION /-7 v' <br /> PUMP INSTALLATION / / PUMP REPAIR /-7, PUMP REPLACEMENT 17 <br /> j Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a -PITPRIVY <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 r= Driven Gauge of Casing Lp <br /> Irrigation Gravel Pack Depth of Grout Seal r ,SQ <br /> Cathodic.Protection j_� Rotary Type of Grout zli r»r o� <br /> Disposal Other Other Information <br /> Geophysical y� + Surface Seal InstalledBy: &4dZZe;d 2 <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pinup H.P. ` <br /> PUMP REPLACEMENT: i /�/ State Work Done <br /> f <br />—jUHP_'.REPAIR:.... /_ /nm---tate mMork Done r-,!- <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> YK <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 FORA GROUT .INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE --� — <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY.- <br /> PHASE I <br /> APPLICATION ACCEPTED BY-' DAT <br /> ADDITIONAL Co <br /> w <br /> wPpi OUT INSPECTION I / NAL INSPECTION s <br /> INSPECTION BY DATE �2• INSP9UjIQNN. DATE - 40 <br /> E H 1426 Rev. I-74 1-74 2M <br />