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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I <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 /> I. 30$V ADDRESS/LOCATIONOf I_ ENSUS TRACT �J <br /> Owner's N ame 4P 4?1 k Y _I� fG I�f�� .,.,._ _`. Phone <br /> Address CityDG_ <br /> Contractor's Na pW,1 , License #/ d-L72-j'Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / +RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other/ / -- <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I. Cable Tool Dia. of Well Excavation. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal n`�\ <br /> Cathodic Protection 1 Rotary Type of Grout �l <br /> Disposal f Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor „ <br /> Type,of Pump er H.P. <br /> PUMP REPLACEMENT. - �TM / / 'State Work Done <br /> # ' ?�,k� 1 / <br /> PUMP`.REPAIR: /}c/ State Work Done 0 f t�f 0-- � ll� rtt <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> li 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 of knowledge d belief, I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO G OUTING AND A FINAL INSP CT N k <br /> SIGNED 'r""~ TITLE da-�' _ t <br /> MRA <br /> W:PL PLAN' ON ERSE SIDE) 7.i <br /> FO&IDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT AT-- f/Gd DATE <br /> ADDITIONAL COMMENTS: `l <br /> PHASE II GR UT INSPECTION 7 PHASE III/FINAL INSPECTION <br /> INSPECTION BY & DATE INSPECTION BY ff"�d DATE <br /> E H 1426 Rev. 1-74 " <br /> 3/.76 2M <br />