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�Q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08�OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zp j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued =ia-7y <br /> .u`` f PaS•4-° :°:' (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 /> S6ret <br /> JOB ADDRESS/LOCATION,Soat JjW ����. ENPU TRACT <br /> Owner's Name At Phone <br /> Address City <br /> Contractor's Name License #/ 71 phone �1� 2 7/0 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7, RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /�(� PUMP REPLACEMENT /7, <br /> Other /'7 <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' I <br /> Disposal Other _..__._.�._ Other Information <br /> Geophysical Surface Seal Installed By: <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. a } <br /> f <br /> } <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: //-K7 State Work Done Cl¢ ro <br /> 8S•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 ani"" a ief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I I <br /> SIGNED - TLE ! <br /> IV (RMMIMT PLAN ON ROE SE SIDE <br /> R D <br /> PHASE I ARTMENT USP, ONLY <br /> ,, <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR INS C I PHASE IIT FINAL INSPE 0 <br /> INSPECTION BY D INSPECTION BY _,5 DAT <br />�a 1.S 1 <br /> E HA1426 Rev. x-74 1-74 2M <br />