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0. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: A 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] -S`7.S` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ., 3--)2 <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 the San Joaquin Local Health District. <br /> •s lc � � `T <br /> JOB ADDRESS/LOCATIONG �a S'�30 ? N#' CENSUS TRACT 1'73-24o-2./ <br /> Owner's Name 62-4L., J''D1' Phone <br /> Address City <br /> Contractor's Name License # Zfa2�rPhone <br /> TYPE OF WORK (Check) : NEW WELL/ ,/ DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <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 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information ' _ <br /> Geophysical Surface Seal Installed By____„___ - <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump ' ✓ H.P. 1.5- <br /> I! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done to <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 puttingthe..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 GRO TING AND A FINAL J.VSC 0 <br /> SIGNED ITLEi�es.l: <br /> �IPRAW P OT PLAN ON RWERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /'/ DATE /0-A 4 <br /> E .H 1426 Rev. 1-74 <br /> 1177 _ 2M <br />