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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,.OFFICE, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.26 ��L711 <br /> r THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatio <br /> n <br /> '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 RCulee' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSLOCATION CENSUS TRACT <br /> Owner'is Name Pf Phone 'CVs t,•. <br /> Address ' 1 0�I f City ' -b C I-0 /0 <br /> Contractor �s Name ___._.._.��"�� W -�,, 4 �T License # 7w,Zftone C16 Z~S S <br /> TYPE OF WORC (Check): NEW WELL -/ DEEPEN '/7 RECONDITION /_7 DESTRUCTION <br /> _ALAREPAIR-/-7-pump ! <br /> • PUMP INST TION /�rPUMP REPLACEME T <br /> Other / / y <br /> -DISTANCE TOINEAREST: SEPTIC TANK SjQ 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 /> 'wyl <br /> Industrial Cable Toole Dia:-of"Well Excavation <br /> Domes:'tic/private Drilled Dia. of .Well Casing / .civ <br /> Domestic/public Driven Y+ _ { Gauge of`Casing /.9k <br /> V7'F Irrigation Gravel Pack " " Depth of Grout Seal <br /> Cathodic .Protection Rotary Type of Grout ' <br /> Disposal Other Other Information " <br /> - <br /> Geophysical . -.Surface Seal-Installed-.B <br /> PUMP INSTALLATION: ' <br /> Contractor'' <br /> N <br /> . • Typey, ofH.P. <br /> j+ y i <br /> PUMP- REPLACEMENT: ' /�/ State Work'Done <br /> � <br /> PUMP�.REPAIR'I ` `/„_/ y YState--Work Done <br /> bES•TRUCTIONI OF WELL t. Well'Tiiameter Approximate Depth <br /> ��-��escribe Material an Procedure <br /> C 1 - <br /> I hereby agree to comply with all .lawsand r ulations 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 /> informationl[is true to the-best of- my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING MD A FINAL INSPECTION. <br /> SIGNED �F. TITLE <br /> P (DRAW PLOT PLAN ON REVERSE SIDE <br /> i! FOR DEPARTMENT USE ONLY <br /> PHASE 1 , <br /> APPLICATIOI3.��ACCEPTED BY � DATE �"/� ” `�� T <br /> ADDITIONAL COMMENTS:.,' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPE TION <br />;,INSPECTION BY DATE INSPECTION BY I DATE <br /> E H 14261 Rpv. 1-74 --_ h/75 _2M t - t <br />