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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAiOFFICE.USE: (((/// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z5_/-5 8 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.3-7c <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 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ownei's Name PRo i! C.6 .t ---- Phone - 9z <br /> i <br /> Address City <br /> Contractor's Name License ��o?� Phone vd1 <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN '/-7 RECONDITION /? DESTRUCTION f <br /> PUMP INSTALLATION El PUMP REPAIR / PUMP REPLACEMENT . � <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 4 :,41 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool d.-- Dia. of Well Excavation <br /> Domestic/private rDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection ► Rotary , Type of Grout <br /> Disposal F Other w Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a •- H.P. <br />'r pip REPLACEMENT: /� i State Work Done <br /> k r <br /> `PUMP.REPAIR `"-/7/ State Work Done <br /> ELTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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 Californiapertaining 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 thewell 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. PAF <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> ii FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> b st- <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: = <br /> PHASE II GROUTiINSPECTION PHASE I FINAL IN5PECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 47- <br /> k� i E H 1426 Rev. 1-74 2M <br />