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tea►KnUSE: <br /> SAN JOAQUI,N LOCAL HEALTH DISTRICT <br /> FOF4rOF I 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 iZ/-_741 <br /> (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 wade 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 i? , o:, 'VOOCENSUS TRACT 203--OZ0o/ <br /> Owner's Name !! rp'??C0 ,tx o IS I o h Phone <br /> Address 7 C3 o� City c, <br /> Contractor's Name License #/V ?;,rPhone 6 y,- L <br /> TYPE OF WORK (Check): NEW WELLT7 7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /-J ^� <br /> PUMP INSTALLATION Cl- PUMP REPAIR =7°' PUMP REPLACEMENT %Jr <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 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. �f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump --i-,_ tj H.P. <br /> PUHP <br /> .P,PUMP REPLACEMENT: State Work Done <br /> PUMP :REPAIR; State Work Done ' -,.. - pf 24 <br /> ES•TRUCTION 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 knowledg and-b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND FINAL INSPE I <br /> SIGNED LE <br /> D ce <br /> PEM-PLAN 014 REV SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION B DATE - r <br /> 1 <br /> 9 R 1426 Rev. 1-741-74 2M <br />