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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$.r FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEPJ4IT Permit No.,7 _.!5�e)fo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7 - <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/LOCATION - CENSUS TRACT <br /> Owner's Name @fo�r,-✓ G��.� ,r o Phone <br /> Address F 4:'0'2 '!t City <br /> Contractor's Name &7" License # ? Phone SL,GY 7,�J6 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP PAIR / PUMP REPLACEMENT i7 <br /> Other _K/ �' o -0 i <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> I Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T �. e Atgt,AV H.P. <br /> E .ids <br /> PUMP REPLACEMENT: /7 State Work Done <br /> 1 PUMP ,.REPAIR: LR7 State Work Done,. f .c4 42 4�p= - t-1,. L/ <br /> V , <br /> ES•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 /> WELL DRILLERS REPORT of. the well and nota them before putting. the..well in use.. The above <br /> information is true to the-best of. my kn ed d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALIN E <br /> SIGNED ITLEj- <br /> D W PL LAN ON MERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I E H 1426 Rev. 1-74 <br /> 1-74 2M <br /> .. - <br />