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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i-- 7e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> &(,,7,7iC1• '17J ,�j (Complete In Triplicate) ,. p om-�.--(C o ,gD <br /> Application is hereby made to the Scan 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 Re latAons of the San -Joaquin Local Health District. € <br /> JOS ADDRESS/LOCATION �. F] cs,_ CENSUS TRACT <br /> Owner's Name .)D A0Phone' <br /> Address City <br /> Contractor's Name License #� L� 373 PhonZC(��16.3r`� <br /> TYPE OF WORK (Check): NEW WELL /7DEEPEN / 7 RECONDITION / ,, DESTRUCTION /- <br /> PUMP INSTALLATION C/ PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICIVANK' SEWER LINES PIT PRIVY {' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL <br /> I INTENDED USE TYPE OF WELL TCONSTRUCTION SPECIFICATIONS <br /> Industrial_ w.Cable-Tool -- Dia:of-Wel}...-Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation — Gravel Packl Depth of Grout Seal 1, <br /> Cathodic Protection . 'Rotary ! Type of Grout ' ' <br /> Disposal Ot}ier r Other Information' ' <br /> �. Geophysical Surface Seal Installed `By: <br /> PUMP INSTALLATION: Contr actor ` <br /> Type of Pump H.P. 7S� <br /> PUMP REPLACEMENT: , 13�r 'State Work Don0,t.c.C.r1 . 0 x6e, <br /> t <br /> PUMP :REPAIR-: State� rk <br /> Wo _ ,a" .. ...:.�.�.. <br /> . _ _ Done f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 'f <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 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 GROUG 4D A ' INSPESEON. { <br /> SIGNED TITLE <br /> �. DRAW PLOT PLAN ON REVERSE SIDE17 <br /> .. FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY , DATE f 3 <br /> kADDITIONAL COMMENTS: <br /> r[ PHASE II GROUT INSPECTION PHASE,,III FI AL ,INSPECTIO <br /> INSPECTION'BY DATE ' INSPECTION BY /DATE <br /> E H 1426 . .,Rev. 1-74 4 4/75 2M - <br />