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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Z 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 02 -7, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 elCENSUS TRACT + <br /> Owner's Name Phone .� A< Ge/_3 <br /> Address3_935 S.r ` <br /> City -j�'7'0-C_A ZZI,y_ - <br /> Contractor's Name License # Phone7 <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN _ ECONDITION /_/ DESTRUCTION <br /> PUMP _ CATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 .� <br /> Other u le a <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' Q �f <br /> ,e�­ Domestic/private _77�Drilled Dia. of Well Casing <br /> Domestic/public Driven `+ } Gauge of Casing 1a Z" <br /> ,Irrigation. - ,. ... - -�..:__ - Gravel Pack, Depth-of, Grout' Seal � + <br /> a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical b Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done s, <br /> DESTRUCTION OF WELL: Well Diameter Apprax'mate Depth 4 I <br /> Describe teria and rocedure r� ' <br /> I hereby agree to comply with •all lafs -dd 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 r <br /> PRIOR TO GROU I;V2 AND A FINAL INSPECTION. <br /> SIGNED TITLE f <br /> tee_r�•G,....:- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f V:� <br /> APPLICATION ACCEPTED BY DATE jF 7� <br /> ADDITIONAL COMMENTS: <br /> P 5 I GROUT INSPECTIO PHA II FINAL INSPECTION' <br /> INSPECTION BYDATE INSPECTION BY ' DATE � . <br /> E H 1426 Rev. - I-74 sh 6/77 2M <br />