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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Ofs <br /> Telephone: (209) 466-6781 O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -9-7d <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or ;in'stall the work herein described. This application is made in compliance with San Joaquir <br /> CountyOrdinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 3.5 � e CENSUS TRACT ' <br /> Owner's Name r f Phone <br /> 4 <br /> x Address City <br /> 4 <br /> Contractor's Name PLO License YIW 'hone7 <br /> F j-r .. <br /> k — <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION [—/ DESTRUCTION /-7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other, J / <br /> DISTANCE-TO-NEAREST: SEPTIC TANK Q-- - SEWER LINES PIT PRIVY <br /> _ <br /> __-SEWAGE DISPOSAL- FIELD • ' CESS—POOL/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 /> F �'Domestic/privatebrilled Dia. of Well. Casing 57 <br /> Domestic/public Driven Gauge of Casing �• <br /> Irrigation Gravel Pack .Depth of Grout Seal. d <br /> Cathodic Protection Rotary 9 - Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed BY : <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H•�'•/ _ <br /> PUMP REPLACEMENT: / % "State"Work Done - <br /> PUMP .REPAIR: / / State Work Done <br /> DES•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 <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 /> 1PRIOR TO GROUTING AND A INAL INSPECTION. <br /> 1. SIGNED F. n17 C41 A JZ4 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BY DATE P� 3f 74 _ <br /> ADDITIONAL COMMENTS: <br /> k PHAS I OUT ;NSPECTION PHASE II/FINAL INSPECTION <br /> f INSPECTION BY ATE 7 INSPECTION BYjVA4jLC0tDATE <br /> /t9D,Qkh°s�� <br /> -.,E H 1426 Rev. - I-74 _� _ <br />