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�jSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk 'OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete 3n 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C Ahn; 4,V_L A VF= CENSUS TRACT <br /> Owner s s Name 1 1q�, �j r1 _ Phone ,MIR _252Z <br /> Address - _SA W6 City ���-o'� <br /> Contractor s s Name ��,, ,.V License # c2Z_yQ& Phone <br /> t <br /> TYPE OF WORK- (Check): NEW 'WELL../? DEEPEN '/_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /-7—pump REPLACEMENT /7 <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 /> r 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 1 i .F, s A <br /> 414 Jllel f. <br /> Type of Pump 1 6 H.P. ^/ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�BEPAIR: 7 'St'ate Work Done - <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ^ <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 anew 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 use.. The above <br /> information is true .to the-best' of'my .knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TQ GROUTING AND A FIN I SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY,.-. DATE A/ 74 <br /> ADDITIONAL COMMENTS:' <br /> PHASE II G OUT INSPECTION PHA II F, AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> #. <br /> 4� <br /> E � E H 1426 Rev. 1-74 1-74 2M <br />