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SAN JOAQUIN LOCAL HEALTH DISTRICT fi <br /> FOR!'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> M THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�y"6 d <br /> I (Complete In Triplicate) <br /> r Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> acid/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance. No. 1862 axd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1365 � 2�t CENSUS TRACT <br /> f 1 <br />' Owner's Name ,` n V�a Phone ` 7 <br /> Address City <br /> Contractor's Name . <br /> -�P <br /> License Whone 41 <br /> w TYPE OF WORK (Check) :- NEW WELL '/V DEEPEN -/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INST LA.TION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other' /-7 <br /> -- <br /> DISTANCE TO NEAREST: SEPTX TANK SEWER LINES PIT PRIVY <br /> SEWAGE,-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'C` <br /> i` 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 /> _ Domestic/private r Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .>> Gravel Pack Depth of Grout Se <br /> sA <br /> I Cathodic Protection 1X Rotary Type of Grout <br /> agdg­dl Or <br /> Disposal =. Other Other Information <br /> ' Geophysical Surface Seal Installed B : oon 7 �ryr- <br /> i <br /> PUMP INSTALLATION: Contractor �.. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> State Work Done i <br /> te%Work Dane <br /> I1 <br /> ES1TRUCTION OF WELL Well Diameter 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 regulat.ingiwell construction. Within FIFTEEN DAYS .. <br /> after completion of my work on a new well, I will furnish- the San .Joaquin Local Health District a i <br /> WELL DR ERS REPORT of the well and notify ,them before puttingthe- well in.use.. The above <br /> info at n is rue o the best of my.knowledge-Tandsbelief. I WILL L FOR A GROUT INSPECTION <br /> PRIG T G-ROU71 G AN FINAL; INSPECTION. <br /> Si TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE':ONLY <br /> PHASE I q <br /> APPLICATION ACCEPTED DATE / �5 <br /> ADDITIONAL COMMENTS: w ti <br /> PHASE jj GROUT INSTECTION P S T FINAL INSPECTION <br /> INSPECTION BY '. DATE INSPECTION BY DATE <br /> o -�� �- r <br /> E H 1426 Rev. 1-74 ` "�,p" � �av+ �/ <br />