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SAN JOAQUIN .LOCAL HEALTH DISTRICT - <br /> :OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZLI�1�p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (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 /> JOB ADDRESS/LOCATION <br /> 72� S cENsus TRACT <br /> 1 / 'v r-- <br /> Owner shame Phone ' <br /> J <br /> Address City - - i <br /> 1, Jn , <br /> Contractor's Name � License <br /> � # Ilam,,3 Phone 7-0��F��� <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN/7 RECONDITION /7 DESTRUCTION J/ <br /> PUMP INSTALLATION 1_7 PUMP REPAIR/_7 PUMP REPLACEMENT / <br /> Other j/:1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDEF}USE <br /> PROPERTY LINE PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC..WELL <br /> TYPE OF WELLr <br /> — CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation \; <br /> Domestic/private Drilled Dia. of Well Casiagv <br /> Domestic/public j` Driven 4` "" 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 B <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /77State Work Done p f <br /> PU17r7�� <br /> 'REPAIR: <br /> tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure t <br /> I hereby agree to comply with a1L 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 r <br /> WELL DRILLERS REPORT .of the well and notify them before putting- the.-well- in use... The above <br /> information is true to-th,e•best-of. my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ; TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR PEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY moo--- DATE ' 2Z2 7� <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE FINA1, INSPECTION <br /> INSPECTION BY DATE INSPECTION B . ' DATE <br /> E H 1426 Rev. 1-74 71 U71 • 9M <br />