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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> >1 (Complete In Triplicate) <br /> 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> k 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 /y & o 4 CENSUS TRACT <br /> Owner's Name F S"e r3 Cf C�r Phone <br /> Address lB i.11 - 0 h" � A09�, <br /> City '- <br /> Contractor's <br /> ity 'Contractor's Name 0Ko,.;`� _ //}} <br /> `o, . License # Phone j g s`6 <br /> 1 <br />` TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /y[/ REPLACEMENT <br /> PUMP REPAIR/ / PUMP <br /> Other /% -- <br />' DISTANCE TO NEAREST; SEPTIC WANK 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 <br /> --f—Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing b I <br /> Irrigation #- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other <br /> Other Information � <br /> Geophysical Surface Seal Installed- By: <br /> PUMP INSTALLATION: ContractorR4 S <br /> �� ,� <br /> Type of- Pump <br /> H.P. I <br /> PUMP REPLACEMENT / / State Work Done t <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withtall 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 onla new well, I will furnish the San Joaquin Local Health District <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 />?RIOR TO GR UTING AND A FINAL INSPECTION. p <br /> SIGNED TITLE4(� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHA III INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - E H 1426 Rev. 1-74 <br />