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SAN JOAQUIN LOCAL HEALTH DISTRICT „) <br />' FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephoner (Z09) 4fi6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,--4 -11411, <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/LOCATION00SL-RdCENSUS TRACT <br /> Owner's Name Phone 92&_ <br /> Address 1 _ _ &-L7 1t1�(} 99 _.,,..,,. City <br /> Contractor's Name hennitias2. License #,;qOWPhone 5_%S_qlks� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK awl SEWER LINES PIT PRIVY -- ; <br /> SEWAGE DISPOSAL FIELD aQ[---t CESSPOOL/SEEPAGE PIT ArA_ OTHER <br /> __1'-ROPERTY LINE/a+PRIVATEE -DOMESTIC <br /> STIC WELL G PUBLIC DOMESTIC WELL .�7- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well rr <br /> Domestic/private _� Drilled ' Dia, of_Well Casing <br /> Domestic/public Driven' Gauge of Casing 107 <br /> Irrigation Gravel Pack Depth of Grout Seal A:5[) � <br /> Cathodic Protection Rotary Type of Grout �� r <br /> Disposal Other + Other Information <br /> Geophysical Surface Seal Installed By: <br /> --.tl <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ,tires Describe Material and Procedure <br /> I hereby agree to comply with an laws and r1egulations of the San Joaquin La al 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 GROUTING AND A FINAL INSPECTION. +7 <br /> SIGNED r ` ' TITLE - <br /> -, (DUW JOT PLAN ON REVERSE SIDE) <br /> a; L L. :a �:', t f ' FOR DEPARTMENT USE ONLY <br /> PHASE I f-7 � <br /> APPLICATION Ab� -PTED Y DATE / <br /> ADDITIONAL COMMENTS': <br /> PHASE II QROUT,-INSP QTION PHASE III F N I PECTION <br /> INSPECTION BY 'M" "' DATE., INSPECTION BY DATE <br /> E H -1426 Rev. . 1-74'- <br /> �� 77 - 2M <br />