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C60V VAI, Jv SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. uvo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 ._7�- <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 18§2 and the Rules and Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W.,4A p e'm" ✓ t/)a vs7 F n/r♦ CENSUS TRACT <br /> Owner's Name rr\ 1 h 4 U Phone <br /> Address hl CityOd'` <br /> Contractor's Name m License #/ j'_P hone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN17 RECONDITION /-7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION /LC/ PUMP REPAIR / / PUMP REPLACEMENT J <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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _! Industrial Cable Tool Dia. of Well Excavation <br /> " --_Z Domestic/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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,. �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP ' s /,�C/ State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter <br /> 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 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 o y knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL _jWggC1O <br /> SIGNED ¢i ITLE � <br /> PLOT PLAN ON NVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -` <br /> -APPLICATION ACCEPTED BY DATE �p <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHAS IIJFIKAL INSPECTtpp <br /> INSPECTION BY DATE INSPECTIC DATE <br /> t E H 1426 Rev. 1-74 1w,.,„ acvrGc. lcr���J + 1-7�+ 2M <br />