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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: (,,14 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;?7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _2_-&_-Z,,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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Jag ADD' <br /> RESS/LOCATIONS 67 iro�ee7aCENSUS TRACT <br /> Owner's Name ZZ 2 Phoned `Z.. <br /> Address .a ?- �L- /gyp' ��{ 0 City <br /> Contractor's Name - P"M.0f License # Cr7d/ Phone �f{, <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /t* 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 per. <br /> Industrial Cable Tool Dia. of Well Excavation t1^ <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 �� _ v e g <br /> Type of Pump - - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /`/ State Work Done A d d <br /> DES-TTRU_CTION 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 use.. 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 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> PPLICATION ACCEPTED BY �J''!' / DATE 7 Z <br /> )D ITI ONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ',PECTION BY DATE INSPECTION BY DATE 3 - -� <br /> H 1426 Rev. 1--74 1177 2M <br />