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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'VOF-.OFFICE USE: 1601 E. Hazelton Aye Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.%Z2�52 <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. i <br /> JOB ADDRESS/LOCATION CENSUS TRACT I <br /> I <br /> Otaner's Name ja e �/vim z Phone �f7�;-,C�,•�3� <br /> Address .2.4/157 [1--4 <br /> City <br /> City <br /> Contractor's Name License Phone <br /> �i <br /> TYPE OF WORK (Check) : NEW WELL , DEEPEN / / RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION /4/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: i-SEP,TIC TANK 1Zp SEWER LINES PIT PRIVY <br /> --SEWAGE-;DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT i 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 /> x Domestic/private' r 'Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation "�Gravel Pack Y —_.v. <br /> _ Depth of Grout Seal <br /> Cathodic Protection -7 RotaryType of Grout _ _ �' °ice <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed B Gtr <br /> PUb& INSTALLATION: Contractor !� e <br /> Type of Pump � .ZJ7- <br /> = �..� r� ,_,.Q..._ H•P• <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION -NF 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 />` Arid the State of California pertaining to or regulating well construction. Within FIFTEEN DAIS <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_ t._of-my-know.ledge-and- belie€---I--.W _-GSL-.�-FGR-Ar-GROUT INSPECTION <br /> PRIOR TO GROUTING AN <br /> SIGNED •, .. , , TITLE <br /> (DA PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `r <br /> APPLICATION ACCEPTED BY DATE <br />� ADDITIONAL COMMENTS: <br /> ` ., PHASE II GROUT INSPECT ON _ PHASE II FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 5ti <br /> r <br />€' E -H_1426 Rev. 1-74 ! 1177 2M <br />