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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ZS <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 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 Q Alr CENSUS TRACT <br /> Owner°s Name L Phone <br /> Address ��, 4 f City l� <br /> Contractor's Name .,,7rV S Z2 7P PY-Z. <br /> a/1/(2 E_ License / ` -Phone�7(Ao <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTLATION PUMP REPAIR / 7PUMP REPLACEMENT <br /> Other <br /> I` a <br /> DISTANCE TO NEAREST: SEPTIC TANK DO SEWER LZ ES 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 /> s Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: r z T <br /> I� PUMP INSTALLATION: Contractor R V) /VC E - <br /> Type of Pump nit F $i L3L. , H.P. ;z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and .Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish -the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well in-use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING FINAL INSPECTION, <br /> SIGNED TITLH��- ��_2 <br /> p - (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / y- <br /> ADDITIONAL COMMENTS: <br /> P GROTJT INSPECTION ' ' INSPECTION BPHASE FIN IN$PEECTION <br /> INSPECTION BY ATE Zg <br /> } //E H 1426 Rev. .1-74 1-74 2M <br />