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n S <br /> VVV - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,6`_ '3o6r.J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued -1 -fit <br /> (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 _ILL cAllwa &I -7ne b <br /> __1WfjLAA1JjCENSUS TRACT <br /> Owner's Name lyr <br /> Phone <br /> Address <br /> City <br /> Contractor's Name �3 <br /> .License # 0&0 Phone <br /> TYPE OF WORK (Check): NEW WELL 'jF DEEPEN RECONDITION /_7 DESTRUCTION f7PUMP'INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other %/ .— <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_U_S_E 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 116 (� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 4 <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ° <br /> H.P. . <br /> PUMP REPLACEMENT: ' / State Work Done <br /> PUMP ;REPAIR: / / State Work Done <br /> IJ//kA�JelG -Cf z- to <br /> S TRUCTTON OF L: ell Diameter Ap oximate 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 <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 GR UTING AND A FI INSP IO /? <br /> SIGNED CMCJ. LE _17711 ez� <br /> DRAW P T P ON REVERR SIDE <br /> FO <br /> PHA DEPARTMENT USE ONLY <br /> AP—.. S�I � p�� <br /> PLICATION' ACCEPTED BY / DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHA II INSPECTI <br /> gN <br /> INSPECTION BY DATE INSPECTION BY. -4z DATE <br /> 2 H 1426 Rev. 1-74 - arra 1 /75 2M <br />