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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE; 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7l <br /> THIS PERMIT EXPIRES l YEAR FROM DATE -ISSUED Date IssuedZ <br /> (Complete In Triplicate) le 7- 2-30-L9 <br /> Application is hereby made to the San Joaquin Local health District for a p6rmit 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 /> �"T <br /> JOA ADDRESS/LOCATION I lf-A S T o FA R AING T Al o!V S o cU ,Sr S/,09SUS TRACT <br /> Owner's Name = 'r// ,4 : M w R Phone <br /> Address <br /> b -7 : .IC <br /> i <br /> City 84RM1N4 Ta Ale L <br /> Contractor's Name License #S~lS ( Phone -- <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/7 RECONDITION /_7 DESTRUCTION / i <br /> PUMP INSTALLATION/ / PUMP REPAIR 7 PUMP REPLACEMENT- <br /> Other / / k <br /> i C$ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE 5 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 /> .� 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 t Rotary Type of Grout <br /> Disposal Other , other Information . ' <br /> l <br /> Geophysica : <br /> Surface Seal Installed By:' <br />.PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. 'a <br /> PUMP REPLACEMENT: <br /> /_�(/ State Work Done + <br /> I ti, e p Jn, e <br /> PUMP .REPAIR., / / State Work Done <br /> DESjTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 i <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 INSPECTI <br /> PRIOR Tn GROtlTING AND A FINAL INSPECTION. ON <br /> SIGNED TITLE <br /> �DRAOPT�A �OR EVERSE SIDE <br /> �j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY f i <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H:. 1426Rev. <br /> 1-74 <br />