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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> { APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT a. 7777- <br /> Z <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE `ISSUED Date Issued 6 <br /> (Complete In Triplicate) <br /> Application =is hereby °.made to' the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made 'in compliance with .San Joaqu <br /> County Ordinance No."A62 arid the Rules and 'Regula tions of the San Joaquin,Local Health District <br /> 4 JOB ADDRESS/LOCATION_ Ii - CENSUS TRACT_ <br /> Owner's Name LR =� � HEA <br /> Phone <br /> Address �?k0_ � C'2 .City <br /> s Contractor's Name �� P License 1176�QZ Phone <br /> E <br /> TYPE OF WORK (Check)4: ­ ,NEW WELL . /: DEEPEN %/ RECONDITIONS"/�./ DESTRUCTION <br /> `_" PUMP INSTALLATION,j-,LATION,fW//, PUMP REPAIR / / 'UMP REPLACEMENT <br /> Other <br /> F 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 Cable Tool 'Dfa: of Well Excavation <br /> _ Domestic/private. Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing ,W- Z <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal i Other Other Information <br /> Geophysical' • - Surface Seal Installed B <br /> PUMP INSTALLATION: t icontractor' <br /> HP. <br /> . <br /> Type of Pump . . . . <br /> PUMP REPLACEMENT: � <br /> / / ' State Work Done d< <br /> PUMP REPAIR: / / State' Work Done <br /> a <br /> i.DESTRUCTION OF WELL: Well -Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comp�ly ,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 <br /> WELL DRILLERS REPORT of the raell_ and":notify them before putting the well in:-use. The 'above <br /> " information s true to-the-best of my knowledge and belief. I WILL CALL FOR A GROUT 'INSPECTION <br /> PRIOR TO GJ10UTING AN . �A F ' INSPE ON. <br /> SIGNED :,/ . � . / TITLE <br /> d Ali , (DRAW PLOT PLAN ON REVERSE SIDE) : <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTED B DATE <br /> 11 <br /> ADDITIONAL COMMENTS: <br /> ¢ PHASE IIIIGROUT INSPECTION P /FINAL INSPECTION <br /> �{ INSPECTION BY I� DATE JNSPECTION BY % DATE ���1� <br /> E H 1426 Rev. 1=•74 .-_ .... . <br />