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SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone.: (209) 466-6781 <br /> APPLICATION FOR- WELL CONSTRUCTION OR PUNT PERMIT Permit No. 2 ,rz1a,7 <br /> 7d .. ,298 � <br /> THIS PERMIT EXPIRES 1 .YEAR�FROM DATE ISSUED Date Issued 4�- -ZG <br /> (Complete In Triplicate) <br /> Application, is hereby made to� the Son 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 .Sanr-Joaquin Local Health District.:', <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner f s Name Phone , (3-E2 - (2-3-Q9 <br /> Address p litl City <br /> t . ;- . w ' � �_-X1 691 <br /> ,Contractor's Name License ' hone <br /> TYPE r�•- <br /> OF WORK (Check)�-i NEW-WELL;"2W"'DEEPEN' i7 `RECONDITION %T DESTRUCTION T/77 <br /> PUMP INSTALLATION I PUI+g' REPAIR /� PUMP REPLACEMENT % f <br /> Other,�/�/ is --- <br /> DISTANCE TO NEAREST: SEPTIC .TANK S{ SEWER LINES PIT PRIVY , <br /> SWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/$PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE _F TYPE OF WELL <br /> -�. CONSTRUCTION SPECIFICATIONS <br />" Industrial. 'AJ it Cable Tool Dia. o£ Well Excavation ;gip �► <br /> Domestic/private i! Drilled Dia. af-Well.Casing " '►$ <br /> Domestic/public T# ,.DrivenGauge of Casing ! / .� ..: Yr <br /> Irrigation li `�Gravel� Pack Depth of Grout Seal <br /> Cathodic Protection !I "Rotary Type of Grout ��__ J <br /> -Disposal €i -Other Other Information <br /> R Geophysical y Surface Seal Installed By: ' <br /> S.. <br /> PUMP INSTALLATION: k Contractor ; <br /> Type c f Pump H.P. <br /> PUMP REPLACEMENT: . 1. /% State Wori Done <br /> PUMP 'REPAIR: i / / State Work Done <br /> DESTRUCTION OF WELL:F 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.furn' ish-'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 /> inf ormation is true to the•best-of my.:knowledge�4nd belief: ' I WILL CALI, FOR GROUT INSPECTION <br /> PRIOR TO GR TING 'AND AaINAL INSPECTION. !} <br />' SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A#LICATION ACCEPTED BY X .' DATE5-- 1 7C <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION ar PHASE INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE `I6 <br /> GO�']� <br /> E!%h�IG26 Rev. 1-74 �- 4/75 2M ((f <br />