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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rJ / � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /'�.2 7-7e <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 /> ,TOE ADDRESS/LOCATION � 95-S CENSUS TRACT <br /> Owner's Name µw e, 7 Phone <br /> Address16 VSS <br /> a A S( City frcd zo�v <br /> Contractor's Name e0 t IP 6,,ex 4 License " Phoney--& - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/A"--f SEWER LINES - PIT PRIVY q� <br /> SEWAGE DISPOSAL FIELD / CESSPOOL/SEEPAGE PIT OTHER y4 <br /> PROPERTY LINdd+PRIVAT'E 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 r Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1�,- Other Other Information, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ee Wj'o k L , :,/`cam w e <br /> Type of Pump — -- H.P. <br /> .�,..._... <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-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 we11•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 OUTING D A FINAL INSPECTION. <br /> SIGNED h • e TITLE,.. - --- - - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I = <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N P SEI /FINAL INSPECTION <br /> INSPECTION BY DATE jLV INSPECTION ATE ,Jr <br /> E H 1426 Rev. • 1-74 b/77 WM <br />