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/ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> 3 Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued x. - 749 <br /> t (Complete In Triplicate) <br /> Application is Aereby`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 egulations of the S n Joaquin Local Health District. <br /> UA-Pg®Ejiw- <br /> JOB ADDRESS/LOCATION CENSUS TRACT' <br /> Owner's Na IV' ! Phone R fFr �3 <br /> ' Address Lqqo City <br /> Contractor's Name *` L IVC, License j -FS/Phone { --Q �-�y, <br /> t <br /> r <br /> t TYPE OF WORK (Check) : NEW WELL /7�p--DEEPEN / / RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / [?MP REPAIR / / PUMP REPLACEMENT <br /> .�; Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LNES PIT PRIVY J <br /> j ' <br /> SEWAGE DISPOSAL FIELD,40 O CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL '""` PUBLIC DOMESTIC WELL." <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> F< b Industrial" Cable Tool Dia, of Well Excavation <br /> A---ftmestic/private Drilled Dia. of Well Casing <br /> R Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _, r <br /> Cathodic Protection —4,,-- Rotary Type of Grout d-A.1- <br /> Disposal Other Other Information 5 <br /> Geophysical Surface Seal Installed B -, G� <br /> PUMP INSTALLATION: ContractorAo <br /> TMr � . <br /> f <br /> Type of Pump X H.P. <br /> `-. <br /> PUMP REPLACEMENT: / / State Work Done <br /> - 4 <br /> IPUMP .REPAIR: / / State Work Done <br /> fDES,TRUCTION 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 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 /> WE DRILLERS REPORT of the well.-ai d, notify them before ,putting the well in use. The above'" <br /> info ation is tru e �- ofE,,my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUTING A AL ' ION. � <br /> ` SIGNED A� TITLE <br /> DPLOT,,PLAN ON REVERSE SIDE) <br /> f <br /> -FOg DEPAR MENT USE ONLY i <br /> PHA �," ,,.�.... -• -�� :� - , . . <br /> DATES' o ,'7 <br /> : APPLICATION ACCEPTED BY w <br /> ADDITIONAL COMMENTS: <br /> P S I GRO T 'INSPECT ON PHASE I/FI INSPECTIOI <br /> INSPECTION BY DATE F INSPECTION B ATE <br /> E H 1426s Rev. 1-74{ <br />