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1/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA+±_OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: -(209) 466-6761 + <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1721- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Tripiicaie) r <br /> Application is hereby made toi the San Joaquin .Local Healthi�jDistrict for a permit to construct <br /> -and/or install the.work herein described. This application :is wade in compliance Frith San Joaquin <br /> County Ordinance No.-.1862-andfithe Rules and Regulations of�iche San Joaquin Local Health District. <br /> 11�1 Ile <br /> JOB ADDRESS/LOCATION �J qv � A��'✓ . � CENSUS .TRACT <br /> Owner P s Name L L /"�✓�" � l Phone, <br /> Address &Ale6 "A Cit- <br /> Contractor'.s Name 79 7p— License #F42-373hone <br /> TYPE OF WORK' (Check) —NEW'WELL /�T DEEPEN '/� RECONDITIN /� DESTRUCTION f7 + <br /> PUMP INSTALLATION /-7 PUMP REPAIR %7 P� REPLACEMENT <br /> Other 7-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4�j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPER TY.LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. 'of Well Excavation <br /> Domestic/private i Drilled Dia. ofoWell Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth off Grout Seal � <br /> Cathodic Protection I Rotary Type of�jiGrout' <br /> Disposal t Other Other Information <br /> Geophysical. Surfacekeal Installed BY: ... - <br /> PUMP INSTALLATION: Contractor :. <br /> Type of Pump A. H.P. <br /> E PUMP REPLACEMENT: �/ State Work Don , <br /> PUI4 '.REPAIR: /7 State Work-Done <br /> VES-TRUCTION OF WELL: Well :Diameter Approximate Depth <br /> Describe Material and ProcedureI' <br /> I hereby agree to comply with all laws and regulations ofithe 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..weil 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., D A FINAL_ . INSPECTION. <br /> SIGNED w . ', TITLE 1 n/ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k - <br /> APPLICATION ACCEPTED ;BY F : . DATE <br /> ADDITIONAL COMMENTS; !. <br /> PHASE II GROUT: INSPECTION PHA FIN INSPECTION <br /> INSPECTION BY `SATE - - INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />