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SAN JOAQUIN LOCAL HEALTH DISTRICT G / <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , ;Stockton, Calif. D (� � � <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 Aereby 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 ( 0`� SS ��t/ J s7 CENSUS TRACT <br /> Owner's Name Mm (,U j5E 2 j ko Phone <br /> Address a-�fJ � X/ /IGS City <br /> Contractor's Name �p�ili Q l�r �/"(Gll l JkC License # C{ [( f Phone Z <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC—TANK707 SEWER LINFS 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 SPECIFICATI_ S <br /> Industrial Cable Tool Dia. of Well Excavation if <br /> 'T <br /> Domestic/private Drilled Dia. of Well Casing __1�- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other -7� �9uo0ther Information Ham` <br /> Geophysical j Surface Seal Installed By: p��4-3k!_- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D <br /> APPLICATION ACCEPTED BY DATE -60 <br /> -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> W <br /> N BY TE - - G I SPECT ON B DATE <br /> n,a - ViS1 6r Qp 0 <br /> Gc4 <br /> E H 1426 ev. 1-74 `-/' SO ( 1177 2M <br />