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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0W1OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2g.-, : ,74) <br /> I <br /> i <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date. Issued <br /> j (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 CENSUS TRACT <br /> Owner's Name _r f� IF Z,2 _ff tj 1T T _,_. Phone <br /> Address �/ ` 7_ r✓ �P��' �" _ _ City <br /> f Contractor's Name — <br /> _ � License �G GU /� C0, L Phone g, <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/ RECONDITION / DESTRUCTION /7 <br /> PUMP INST�LATION / / PUMP REPAIR 1-7—pump REPLACEMENT /7 Al <br /> Otherp/ <br /> / — <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ,rte OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> .Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \l <br /> Cathodic Protection Rotary Type of Grout' V <br /> —Disposal —Other—. Other Information <br /> Geophysical Surface Seal installed B : - <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type ***of��_- Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> ' / / State Work Done_ <br /> PUMP '.REPAIR: ..T <br /> • %7 State. - <br /> Work Done <br /> — d <br /> E&TRUCTIONjOF WELL: `Well Diameter Approximate Depth <br /> Describe Material and Procedure p <br /> I hereby agree_to comply with-dll laws and regulations of the San Joaquin Local Health District <br /> and the State of 'California pertaining to or regulating well construction. <br /> ., a 8 $ n. Within FIFTEEN DAYS 'll <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a I' <br /> WELL DRILLERS REPORT of the 'w�ll..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 FORA -GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSPECTION: <br /> SIGNED ' <br /> TITLE <br /> (DRAW PLOT ,PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS. <br /> • a <br /> P i G UT INSPECTION. . PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> E H 1426 Rev. 1-74C -�'r <br />