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, ? "'N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16Lr E. Hazelton Ave. , Stockton, Cal... . <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 to the San Joaquin Local Health Districttaru <br /> a e c struct <br /> and/or install the work herein described. This application is madec San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San e th District. <br /> JOB ADDRESS/LOCATION _�6D5(7 IV,, PD CENSUS TRACT <br /> Owner's Name Phone LZ <br /> Address /y City <br /> Contractor's Name r�i�fX1¢� IC�cLL. ,,0,C/LZ-1'1re4- W-1140 <br /> License 11 11,7�2�1 Phone <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /7 <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 <br /> Industrial moble Tool Dia. of Well Excavation Jam_ O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing la <br /> Irrigation Gravel Pack Depth of Grout Seal 5 O <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical // Surface Seal Installed By: 3 <br /> PUMP INSTALLATION: Contractor 1'/�Q( /lC/O2�S , <br /> Type of Pump S�—T H.P. - `' %� — C_ <br /> PUMP REPLACEMENT: / / State Work Done 5 <br /> PUMP '.REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING ADNA FINAL INSPECTION. <br /> SIGNED t," ,, TITLE O <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE Z FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Sf DATE 7 j- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHASE III/FINAL INSPECTION <br /> INSPECTION BY �. , INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 _�i <br />