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x r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOArOFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ir �!l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-14 _7q 5 <br /> (Complete In Triplicate) i <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 <br /> JOB ADDRESS/LOCATION CA4,j cENsus TRACT <br /> Owner s Name <br /> Owner' J Phone "'4y3 -- /,6 3,3 <br /> i <br /> Address <br /> 1D09 c cityui'r�2<�-rl <br /> Contractor's Name 2 License # 99e,-13 Phone <br /> TYPE OF WORK (Check) : -.NEW-WELL DEEPEN"./_7 RECONDITION / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other j/7 <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 DOMESTICWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �- Domestic/private Drilled Dia. of Well Casing s ,� <br /> Domestic/public Driven Gauge of Casing I <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: h -- -- <br /> ,PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> r. <br /> PUMP REPLACEMENT: / / State Work Done <br /> �. J <br /> PUMP:REPAIR: State Work Done <br /> ' ES.'TRUCTION OF WELL: —Waif Diameter- Approximate Depth I <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sar: 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, T will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well 'and notify them before putting the .well i. n.,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 D FINAL NSPE ION. <br /> SIGNED TITLE <br /> ( W <br /> PLOT PLAN ON RSE SIDE <br /> FOR DEPaTMgNT USE ONLY v <br /> PHASE I 41 i <br /> APPLICATION ACCEPTED D E u - <br /> ADDITIONAL CO <br /> P ROUT INSPECTIONTTI F SPECTI N <br /> INSPEC N BY DATE '- INSPECTION BY ATE . —Z <br /> -E H 1426 Rev. 1-74 1-74 2M <br />