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�j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO9(OFFICE USE: 601 E. Hazelton Ave.', .Stockton, Calif. ' <br /> Telephone: (209) 466-6781: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t. s$ � <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tothe 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 Ca ` L�2. E. Ph"' �t CENSUS TRACT <br /> Owner's Name Rd 4. Phone ,C ' <br /> Address •7 U-14,_ C fiJ I ("t _ _ City <br /> a <br /> Contractor's Name �o License # Phone ,S'�T'.3 �,�(,� � <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION t PUMP REPAIR / / PUMP REPLACEMENT /7 R <br /> Other : / <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 V <br /> Industrial r Cable Tool. Dia. of Well Excavation <br /> Domestic/private r Drilled Dia. of Well Casingi <br /> Domestic/public r Driven Gauge of Casing IN <br /> �y__- 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: Contractors <br /> Type of Pump S 6—=1 Lk H.P. Z O <br /> PUMP REPLACEMENT: 1 / State Work Done <br /> PUMP `-REPAIR: 1-7 State Work Done - <br /> PES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> il : <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,%_l will furnish the Sao, 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 GROUTING AND A FINAL INSPECTION. > <br /> SIGNED 1 i TITLEc+-�r9 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /tJ. DATE -7 <br /> ADDITIONAL COMMENTS: I L Z7 <br /> PHASE I%foR%T, IMPECTION PffASE IN NSPECTION <br /> ai INSPECTION BY DATE INSPECTION BY ATE -z -lo"—ZZ <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />