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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:,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 <br /> (Complete In. Triplicate) <br /> Application is hereby made t I <br /> o 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 S�- W <br /> RO E r k F s 77/Mrod CENSUS TRACT ' <br /> SOUTH TO frbHT l jl6-E Ru, <br /> owner's Name a�'L - IZ Phone ,-C207) 3 69- 0 9S <br /> Address do' Z-2-1 llldTD2 e4L 9S2 City . . <br /> Contractor's Name License # Phone <br /> TYPE <br /> Y OF WORK (Check): NEW WELL L7 DEEPEN '/? RECONDITION %7 DESTRUCTION /f <br /> PUMP INSTALLATION /—/ PUMP.REPAIR /-7—Pump REPLACEMENT <br /> Other ITI Ce rz-0 pWlt° L 7 rs <br /> LEE 5 <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 j <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -,'Domi�sric/public - ' . . - -- ,Driven - s 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 ---.�_ <br /> Surface Seal Installed 'By: <br /> PUMP -INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT 4 <br /> . , / / Sate Work Done <br /> PUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure "` <br /> 4 <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 anew 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 AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE # <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> :EOR DF.PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f f i <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' -/ ' . <br /> E H 1426 Rev. 1-74 i.,.- <br />