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!✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 75 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made too the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin] <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION.,J j //i ,� (1 i(? l '� CENSUS TRACT <br /> Owner°so Name �!' &WI - _ l� F�'oGL- Phone,,?- <br /> _7A / <br /> Address .2 l /a # `I c?Ci.� City <br /> Contractor's Name License 69 Phone�j <br /> I� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 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 4� <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 1.7— <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> 4 Cathodic Protection A Rotary Type of Grout <br /> 'Disposal ' '.1 Other Other Informati n <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUM .REPAIR: /? State Work Done <br /> JI a <br /> ,RE5 TRUCTIONOF WELL; Well Diameter Approx ate Depth , (� <br /> -. Describe Matdria nd Procedure <br /> I hereby agree to comply-w all aws 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--I <br /> PRIOR TO GRO TING ANDA gINAL INSPECTION. <br /> SIGNED TITLE4&, 4,2 <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> ` FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY (, DATE //-2 9-7Y <br /> ADDITIONAL COMMENTS; 1 <br /> PHASE II GROUT INSPECTION PHASE III - INAL INSPECTION � <br /> INSPECTION BY ��DATE -�/� INSPECTION BY DATE /6,1- <br /> E <br /> `E H 1426 Rev. 1-74 1-74 2M <br />