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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ^ <br /> FORO 'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -ILI =� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedL-T-7� <br /> 2 SS S"• l-E oc r 6�a -�-D (Complete In Triplicate) 17o--oq <br /> Application is hereby made to the San Joaquin Local Health District for a permit tb 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 /> A <br /> 30B ADDRESS/LOCATION aOs re, aAQ /_ " APaCLMSUS TRACT <br /> Owner v s Name _ I- - Phone <br /> Address R"' $ f <br /> /' eCity <br /> r <br /> Contractorlo Name :° License # ;, _,Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR 1-7—PUMP REPLACEMENT <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled 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 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump + H.F. A <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> 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 ease. 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 I ON. <br /> SIGNED °' TITLE p/ _ <br /> (DRAW PLOT PLAN ON EASE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY (3-( DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 ' .E H 1426 Rev. 1-74 �, <br />