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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. HazeltoiT Ave';,Stockton, Calif. 'v <br /> r Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-n <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZZ4� � <br /> l t (Complete In Triplicate) x <br /> r Application is Aereby 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 /> [ JOB ADDRESS/LOCATION h .-� -_F TRACT <br /> Y Owner's Name CQ. r ' + Phone 5 <br /> f Address a334k, <br /> Cit j a0l <br /> Contractor's Name <br /> . .License # 0 /� Phone - <br /> ' i'� sD0 .4� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f� <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. IQ2' <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 _ Rotary Type of Grout Q, <br /> Disposal Other Other Information. ICS <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` !, o w6 LL )A/ 61 <br /> Type of Pump H.P. r <br /> ► <br /> �. ' <br /> IPUMP <br /> REPLACEMENT: / / State Work Done <br /> PUNT -REPAIR: / / State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Vnl1C <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 /> lafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FWELL 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 /> PRIOR TO GR, TING AND A FINAL INSPECTION. <br /> SIGNED ' TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> k - FOR DEPARTMENT USE ONLYPHASE I <br /> r <br /> ':APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE /FIN INSPECTION <br /> INSPECTION BY DATE # INSPECTION BY "}►DATE / 1 q `) <br /> 1 d <br /> R H 1426 Rpv. 7-74 _ _ <br />