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SAN JOAQUIN LOCAL HEALTH- DISTRICT i <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2T /7A&_) <br /> t <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONG410AICENSUS TRACT <br /> Owner's Name Phone <br /> Address 1-76Z -5 <br /> City <br /> Contractor's Name _5 ZNC , License 4*26079V Phone/?-V <br /> TYPE OF WORK (Check) : NEWWELL DEEPEN/ / RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTLLLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other J-7 <br /> 4 <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 � 1 <br /> INTENDED ,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \(. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing fir <br /> Domestic public f <br /> / Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ---- <br /> Disposal Other Other Information s <br /> Geophysical Surface Seal Installed By: d t`C 1 JG'� t <br /> - ..�!?AC_1�. <br /> PUMP INSTALLATION: Contractor /I C <br /> Type of Pump H.P, 0� <br /> PUMP REPLACEMENT / / State Work Done <br /> POMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> • Describe Material and Procedure <br /> Ikvtareby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> drid"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 /> WELLDRILLERS REPORT of the well andnotefy them before putting the well in use. The above 'kinformation is true to the best of- my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROPTING AN A KNAL INSPE.CTION. <br /> SIGNED TITLE <br /> DRAW PL T PLAN' ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE AWFINAI, INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE/ /e 7 <br /> E H 14263f=f� <br /> Rev. 1-74 � <br />