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lam" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , Permit No. 7,6-LEI," <br /> THIS PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sar: 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 V w�s�` G, CENSUS TRACT <br /> Owner's Name LcJ,C,rzrr�c�� ,� ('��Q �, Phone 3 6 :r`/.`/ <br /> Address .-� G 4v City <br /> Contractor's Name �. License #16.13 2-2 Phone36 ll --C?36' <br /> TYPE OF WORK (Check) : NEW WELL ,/-7 DEEPEN -/ 7 RECONDITION /7 DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR fi< <br /> 77PUMP REPLACEMENT %J" <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE WMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �j <br /> Industrial Cable Tool Dia. of Well Excavation C-11 <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �O <br /> PUMP REPLACEMENT: . /-7 State Work Done <br /> PUMP 'REPAIR: State Work Done p <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth j <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 a J <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 I <br /> PRIOR TO GRO N AND NAL INSPECTION. i <br /> SIGNED TITLE r <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I DEPART 'NT USE ONLY <br /> APPLICATION ACCEPT DATE ' -/Z `7-1-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 X1/75 2M <br />