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I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22L�7P <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 /> iCounty Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�a a&.6c CENSUS TRACT <br /> Owner's Name L! Phone <br /> Address /1_77 L iF2a i.2_ ...,, City . . <br /> Contractor's Name F <br /> r License V/ff�?,j Phone � ,•776 <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN '/? RECONDITION /,7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR /rte/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'X <br /> ` PROPERTY LINE » PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELT, <br /> " I"INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ -Driven a Gauge' of--Casing' .-- _ 1�A <br /> Irrigation Gravel Pack Depth of Grout' Seal <br /> :Cathodic Pr_otec ion i Rotary Type of Grout i <br /> Disposal Other Other 'Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION.- Contractor <br /> Type .of Pump H.P. 30 1 <br /> PUMP REPLACEMENT: / / 'State Work bone <br /> PUMP `.-REPAIR: State Work Done <br /> y 5 4 1 <br /> DESTRUCTION OF WELL: Well Diameter rt y " <br /> � w •Approximate Depth <br /> ` ." Describe Material and Procedure <br /> I hereby agree tooccomply with. all -laws4and-�regulatiaiis-bf the San Joaquin Local Health District <br /> and-the"State. of,'Californfa pertaining to or regulating well."constructi.on. Within FIFTEEN DAYS <br /> after completion of my work- on a new well, I will furnish the San Joaquin Local Health District a p <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 y.. 0 ledge a. belief. I WILL CALL FOR A GROUT INSPECTION` , <br /> PRIOR TO G ING AND A FINAL INS IO <br /> SIGNED -TLE <br /> W PLO LAN ON' SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .1 <br />'APPLICATION ACCEPTED BY Z-11 - f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE -W WOUT INSPECTION PHASE III FINAL'INSPECTION <br /> INSPECT$ON BY, z4zAtDATE INSPECTION BY F DATE <br /> E H 1426 Rev-1-74- h/75 2M <br />