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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l 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 6F A R G �� CENSUS TRACT <br /> Owner's Name J 1 <br /> 1 ,� 1� Q Phone <br /> Address 23 6 0 V �t .� F City � ` �. <br /> Contractor's Name f, fIL, ,l C6 04) , License #76 6 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / J RECONDITION /_/ DESTRUCTION /-7 <br /> f PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other / <br /> DISTANCE <br /> TO NEAREST: SEtTIC 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 /> ustrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled . 7 Dia, of Well Casing <br /> Domestic/public Drive Gauge of Casing <br /> Irrigation <br /> QTeErvel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary F Type of Grout �?— <br /> Disposal Other Other Information <br /> Geophysical Surface -Seal, Installed B �1 <br /> F �r �' . 4 . , r <br /> 'PUMP INSTALLATION: Contractor f <br /> Type of Pump .. -� r. ... _ • , - .•...— <br /> PUMP REPLACEMENT: <br /> S tate Work Done <br /> POMP .REPAIR: State Work Done <br />,DES•TRUCTION OF WELL: Well Diameter Approximate ,Depth <br /> e <br /> DescribMaterial and Procedure ! �,.:,. <br /> R• T <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 GROUTING ANDA INAL INSPECTION. <br /> SIGNED Qy ,. TITLE <br /> _(DRAW_ 'OT WPLAN_AN.-REVERSE .SIDE) <br /> - <br /> 4�A,,,,,LOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: r ' <br /> PHASE II GROUT INSPECTION P I/FINAL INSPECTION <br /> INSPECTION BX DATE _ -�?j-")1 INSPECTION BY DATE �11 <br /> E H 1426 Rev._ 1-74 11Z7 <br />