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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 71-- <br /> ___THIS PERMIT EXPIRES 1 YEARFROMDATE ISSUED Date Issued �7 7S <br /> tA-M( 7&--,90.J. z X0:� (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 /> ' f <br /> :TOB ADDRESS/LOCATION US /. 9� CENSUS TRACT <br /> Owner's Name toC Phone <br /> Address R S '-tl C� ,.�N City Zo 9 <br /> Contractor's Name , l i-1R D.0 - _ License #: y�Phone ' <br /> TYPE OF WORK ,(Check):, NEW WELL/J�? DEEPEN / RECONDITION /-7 � DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT— 17 <br /> i N �. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r <br /> . PROPERTY LINE - PRIVATE DOMESTIC WELT. PUBLIC DOMESTIC WELL <br /> i NTENDED USE j TYPE OF WELL . _ _ „CONSTRUCTION SPECIFICATIONS <br /> ' Industrial :+; Cable Tool } Dia.- of Well -Excavation <br /> �. <br /> .Domestic/private Drilled Dia. of Well Casing <br /> =.Aomestic/public Driven Gauge of Casing f �- <br /> irrigition L ��avel Pack Depth of Grout Seal <br /> _ Cathodic Protection �/ltotary Type of,.Grout,. -► i c <br /> Disposal Other Othe�� Information <br /> Geophysical Surface Seal-,Installed By: <br /> PUMP INSTALLATION: Contractor YS ;1 <br /> Type of PumpCiil+rt - _ , H.P. S <br /> PUMP REPLACEMENT: / / State Work Done," <br /> PUMP-'.REPAIR-: State-Work Done�i <br /> E&TRUCTION OF WELL: Well Diameter A ; 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 m 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,' se. The above <br /> informa't'ion-is-true-to-the best-of' my knowledge-and°-belief. 'I- WILL CALL `FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED ` � t TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT IWSPECTION PHASE III FINAL INSPECTI2 <br /> INSPECTION BY DATE 7 d2 Z 7": INSPECTION BY ' , DATE <br /> �_�' E H 1426 Rev. 1-74 1-74 2M <br />