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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7S 1k 9Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l <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 �730 CENSUS TRACT <br /> Owner's Name ` .Q/z�C�� - Phone L6 -V'17-7�d- <br /> Address _. City <br /> Contractor's Name License #4,;?IQ1r.2Phone <br /> TYPE OF WORK (Check) : NEW WELL /,I DEEPEN/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSfZLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br />- DISTANCE TO NEAREST: . SEPTIC TANK 6iD 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 -/=P- <br /> Domes <br /> cP. <br /> Domestic/private4--Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 160 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _1—Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:- „B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESS 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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING AND A FIW INSPECTION. <br /> SIGNED TITLE <br /> :�(DRAW MOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE O /�? INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 � 3/7 <br />