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_ f _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNE <br /> OA� <br /> FOFFICE USE: V1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--/91&J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is he eby 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 j—'jj'_ S`/10 L,, /1 CENSUS TRACT <br /> Owner°s Name /� / Phone44 <br /> AddressPW City �-�1— <br /> Contractor's NameI If C/I License #,,�2Z Mhone �►� <br /> TYPE OF WORK (Check): NEW WELL/T DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-j <br /> PUMP INSTAL TION jE/ PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <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 <br /> _j:=-Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing JA <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: <br /> Contractor ' �'/'� ,7 ' ,7� l 1. <br /> Type'of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done _ <br /> ,PES®RUCTION 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 thewell 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 A FIN INSPECTION. <br /> SIGNED TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIDEf� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 74,- LZ—,X)— DATE - 7,S� <br /> ADDITIONAL COMMENTS: <br /> PHAS II �GOUT INSPECTION PHA III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZ 4 Z Vx,a DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />