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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -,5,5 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,5- L']9 , <br /> (Complete In Triplicate) f <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 egulatians of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6 f Op ,. CENSUS TRACT <br /> Owner's Name �� D `hone 3J z/ ' <br /> Address '527 � � City ' <br /> Contractor's Name eo License #42013 Phone <br /> i' <br /> r <br /> TYPE OF WORK (Check) : NEW WELL /lam DEEPEN /% _RECONDITION %_% DESTRUCTION"/-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 } <br /> Other / /. <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 C) <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge' of Casing /` - k (? <br /> Irrigation gavel Pack Depth of Grout'Seal i' <br /> Cathodic Protection ;' Rotary Type of Grout j <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed B <br /> `mak. <br /> PUMP, INSTALLATION: Contractor <br /> • r Type of Pump H.P. <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> .E <br /> PUMP .REPAIR: / / State'Work Done F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of thetSan 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 S�Joan Loc ealth District a <br /> WELL DRILLERS REPORT of the well and notify them before puttinin se. The above <br /> information is true o the-best of- my. knowledge and belief. WFOR OUT INSPECTION <br /> PRIOR TO GROUTINGj4N A FINAL INSP7,RYION. <br /> SIGNEDf TITLE ; <br /> DRAW PLAT PLAN 'ON RE FRSE SI + 1; <br /> F DEPARTMENT USE ONLY vo <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -----i ` <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE. _ t . .INSP ON BY ATE - SL <br /> C'A- I vo 1'R� <br /> E H 1426 Rev. 1-74 �� 3/7 <br />