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jSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 0 <br /> THIS PERMIT EXPIRES 1 YEAR.-FROM DATE ISSUED= -Date IssuedL_1_5 <br /> (Complete In Triplicate): 1. <br /> Application is hereby made;to the San Joaquin Local Health District -for a permit to construct <br /> and/or install the work hekein 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 /> I <br /> JOB ADDRESS/LOCATION . p222w 9-ea"z, CENSUS TRACT <br /> Owner's Name _ Phone <br /> Address v Wv0 �. _ LCity <br /> Contractor's Nam -7i5t� Ff- ,..,.� ��, License # Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ./� PUMP REPLACEMENT .. : <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z_ SEWER`LINES PIT PRIVY, <br /> SEWAGE DISPOSAL FIELD l ►V CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - PRIVATE•ieyr�rJ1\/�ME.. STIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation s <br /> ,Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. o£ Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Px_otection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: /7 State Work Done <br /> PES TRUCTION OF WELL: /AVe31 Diameter '! Approximate Depth ; � r <br /> D scribe Material a d Procedure r <br /> I hereby agree to comply ith all lawsand regulations jDf 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 theta 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 GROUTI G AND A FINAL INSP <br /> SIGNED TITLE0/1 <br /> +r (DRAW PLOT P-LM ON-REVERSE,SID <br /> via <br /> x_ „A wf F2FL-w,DEPART T USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION P I AL INSPEC ION <br /> INSPECTION BY r DATE INSPECTION BY ATE OF <br /> , 1 E H 1426 Rev. 1-74 1-74 2M <br />