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VVV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> wO FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ...,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. s� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z 7-7� <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 Joan <br /> County ordinance No. 1862 and the Rules and Regulations of the San Joaquin qui <br /> ' Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION loA/ � � - CENSUS TRACT <br /> 4 Owner's Name _zl IL 2 6 OR /, <br /> _ 7 <br /> Phone 4.E <br /> I <br /> Address <br /> it �f <br /> City , <br /> Contractor's Name k <br /> ac, License # LJ.3 72,phone y (76 <br /> 1 <br /> TYPE OF WORK' (Check): NEW WELL ly DEEPEN '/7 RECONDITION /_7 DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-J <br /> Other[/ J -- <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 <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing U\ <br /> Domestic/public i Driven Gauge of Casing �. <br /> �[ Irri' ation �- <br /> 8 .� Giave1 ick Depth of Grout Seal N : <br /> Cathodic Protection N-1 Rotary Type of Grout <br /> Disposal t <br /> Geophysical Other Other Ynformation <br /> �,. <br /> Suxface Seai Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 4. <br /> Type of Pump .„b , H.P. <br /> PUMP REPLACEMENT: <br /> j/:/_ Sr ate Work Done <br /> PUMP :REPAIR: - H State Work Done <br /> E&TRUCTION OF WELL: Well Dliameter <br /> Describe Material and Procedure Approximate Depth <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--completibw bf My..work on a new well, I will' furnish the San Joaquin Local Health District a C <br /> WELL DRILLERS REPORT of the will and notify them before putting the well in.use.. The above i <br /> information is true to the-best•of .my-ktto le gefand lief I WILL CALL FOR'A 'GROUT INSPECTION <br /> PRIOR TO ING AND A FINAL I ION. � <br /> SIGNED ITLE <br /> T LAN ON SE SIDE <br /> EPART <br /> T USE ONLY <br /> P�IASE ,I N <br /> ����% <br /> APPLICATION ACCEPTSCOQ. <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II ROUT INSPECTION PHASE III FINAL .INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 9 <br /> E H 1426 Rev. 1-74 ' <br />