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SAN JOAQUIN LOCAY HEALTH DISTRICT 'J <br /> y FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 3S'£�,_b. (Complete <br /> + S,_ ,4,x.7- _-_4 -�,o]; In Triplicate) ZS 7-!?©-og:= - <br /> i 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 /> t County Ordinance No. -1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> r <br /> JOB ADDRESS/LOCATION r�� CENSUS TRACT <br /> i J f � <br /> Owner's Name ��� c_ U =: ;' 'r Phone rt;2 <br /> Address J LAI <br /> i 0. City /�?A.►i`� c <br /> f � <br /> Contractor's Name AAPS e—, C License # Phone 3Er l' yS <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 PUMP INSTALLATION -)k/ _PUMP REPAIR / / PIMP REPLACEMENT /_7 <br /> v Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY it 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 I 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 1 <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor' <br /> Type i f Pump ' r H.P. <br /> PUMP REPLACEMENT: ' �.� / / State Work Done - I <br /> PUMP ,.REPAIR: / / State Work Done <br /> L <br /> DES-TRUCTION 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 s <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 GROUTING AND A FINAL- INSPECTION. ; <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHAS I/FI AL INSPECTION <br />' INSPECTION BY . DATE INSPECTION BY DATE - - <br /> E H 1426 Rev. 1-74 U` / o ' 1 f 7) '� M k <br />