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i <br /> SAN JOAQUIN LOCAL- HEALTH DISTRICT -- <br /> FOA++OFFTGE 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 .Y <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Heelth:District for a permit -to construct <br /> and/or install the work herein described. This application is -made In with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p c73 ,_ ���� CENSUS TRACT <br /> Owner's Name Lc. ZU <br /> , Nc� Phone - 7/a3 <br /> Address Ih7 y - _ CityCa�o.J <br /> Contractor's Name e•lt, S ned License � o p .Phone !R,�a-_Wo7 <br /> TYPE OF WORK (Check): 14EW WELL /_7 DEEPEN /? RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR jo PUMP REPLACEMENT /_f ; <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY. 9� .I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER "', <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE OMELTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �1 <br /> Domestic/private ` .q Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 3 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal V ' Other Other Information ' C` <br /> Geophysical Surface Seal Installed By: <br /> 3 <br /> . _ f <br /> PUMP INSTALLATION: Contractor <br /> Type of-Pump H.P. <br /> PUMP REPLACEMENT: j/ / State Work Done <br /> REPAIR: _ - _' / State Work Done 09 - <br /> cr �^ <br /> ESTRUCTION 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 FO A GROUT SPECTION <br /> PRIOR TO GROUTING AND A FiM INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR7!�TMENT USE NLY <br /> APPLICATION ACCEPTED BY, DATE Q <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IaIINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - <br /> r <br /> 3 E H 1426 Rev. 1-74 1_7 A )U -�i <br />