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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FOE OFFICE USE: IE 1601 E. Hazelton Ave. , Stockton, Calif. iLyl- <br /> it Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dare. Issued /1) <br /> _ (Complete In 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 /> II <br /> JOB ADDRESS/LOCATION 71:7�5`� r CENSUS TRACT t <br /> Owner's Name <br /> Phone - 0�- a )2_ <br /> Address/2, City <br /> Contractor's Name 147A -. d{ ° La cense /7_'U�Phone� f <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> i. <br /> Other /_7 . <br /> DISTANCE TO NEAREST: SEPTIC TANK, (J SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL —_ PUBLIC DOMESTIC WELL <br /> INTENDED USE i` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia, of Well Excavation <br /> omestic/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 f <br /> Disposal Other Other Information', w ; <br /> Geophysical - Surface Sea/ Ins <br /> t <br /> alled n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c� - . H.P. <br /> 1� - - <br /> PUMP REPLACEMENT: / I'/ State Work Done <br /> PUMP REPAIR: / If/ StaLq Work Done <br /> ti <br /> DESTRUCTION OF WELL: We'll Diameter � f f Approximate Depth <br /> De"scribe'Material and Procedure <br /> I hereby agree to comply `with all laws and regulationyg 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 fa -new well, I will furiiish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well'4and notify them before puttingthewell in use.. The above <br /> information is true to thle' best .of' my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION., � <br /> SIGNED IN TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f� ��/� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO T INSPECTION PHAS FIN,41, INSPECTION <br /> INSPECTION BY• DATE -7 7 INSPECTION B AT �- <br /> x <br /> E H .1425 _ Rev. 1-74 .F <br />