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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F014;OFFICE•USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . 3 w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued C <br /> f_5- (Complete in Triplicate) 0sa-07 <br /> .Application is hereby made to the Spin Joaquin Local Health District for a permit to construct <br /> and/o�kinstall the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinal No 86. 2 an the R s and Reauations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Off"V�-Y © ��I.yI � < CENSUS TRACT <br /> Owner's Name �aPhone <br /> Address L City <br /> Contractor's Name ":-License' f // F Phone 346d '3'3 <br /> -S - C- <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION !. <br /> PUMP INSTALLATI N / / PUMP REPAIR / / PUMP REPLACEMEN /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERUL <br /> INES�T.' .._-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ,Excavati'on <br /> Domestic/private Drilled Dia, of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information f <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J-1 State Work Done a <br /> PUMP .REPAIR: /-7 State" rke - <br /> � a fF � <br /> 4E5 RUCTION OF WELL: Well Diame er d 'S LG fad 0464- Appro, ate.Dep ' <br /> Describe Material and Procedure 's <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 belie£. . I WILL CALL-,FOR A"GAOUT_INSPECTION <br /> PRIOR TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE ( 7� <br /> (DRAW PLOT PLAN ON REVERSE. SIDE . <br /> ....,,,,,,....,_. --,-.,,.,FOR..DEPARTMENT USE=ONLY • -- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S `;7,9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE rte- r-7�L <br /> `t E H 1426 Rev. 1-74 1-74 2M <br />