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L_d4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. ,®/ <br /> Telephone: (209) 466-6781 '7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .S`34 7,? <br /> (Complete In Triplicate) <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a VCENSUS TRACT <br /> Owner's Name e G r S A eL ccd e✓ .1' Phone <br /> Address �� 0 � � ��r��. t`s City <br /> Contractor's Name4-ALicense # 15a2 ''PhoneSANK A <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> AL <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 q, <br /> Industrial Cable Tool Dia. of Well Excavation } <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � /► Q? �` °' ' <br /> Tyoe of Pump d /,n H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMP R: State Work Done <br /> @J Its t <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 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 /> information is true to the best of my knowle g `n_(f lief. I WILL CALL FOR A GROUT INSPECTION <br /> -PRIOR TO UT NG AND A FINAL IN ON. <br /> SIGNED TLE r <br /> RA P PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��� DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GR INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE V IZ7 <br /> 1177 2M <br /> E H 1426 Rev. 1-74 <br />