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Cn+►�fQ�b� �yJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: ',,- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : -Telephone: (209) 466-6781 <br /> APPLICATION. FOR' WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��-v 5 //0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- f-2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local Ilealth District for a permit to construct <br /> i and/oar install the work herein described. This application is made in compliance with San Joaquin <br />{ County Ordinance No. .1862 ai.a the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ^a� �- d� e� r CENSUS TRACT <br /> Owner's Name r�. Q� Phone , <br /> Address City <br /> Contractor's Name �� .a �cJ License #/Z3 7 2,I phone W i.--?6746 <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN / RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /_1 PUMP REPAIR / PUMP REPLACEMENT f-q <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r,TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4� <br /> Industrial i Cable Tool Dia, of Well Excavation � <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public : Driven Gauge of Casing <br /> iIrrigation �!l . Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection I Rotary. Type of Grout ` f <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor ov <br /> Type!: of Pump r H.P. <br /> +r PUMP REPLACEMENT: } µ /— �- State Work Done - �. - Q - - • - <br /> PUMP :REPAIR: f / State Work Done <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> A. e <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ( and the State of Californialpertaining to .or regulating well•construction. Within FIFTEEN DAYS <br /> r after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ,WELL DRILLERS REPORT of thelwell and notify them before putting the`.well. in.use.... The above <br /> information is true to-the•'6est.of- my- owled a and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTI N. <br /> SIGNED �G/- c.�.r TTLE . . <br /> D W OT `P AN ON RE RSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' ) -� 7 <br /> ADDITIONAL COMMENTS. { <br /> PHASE II GROUT INSPECTION PHASE III TNAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE , 7 <br /> E H 1426 12Pv_ 1-74 ZM <br />