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` SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOBiOFFICE USE: 1601 E. ,Hazelton Ave. , Stockton, Calif.. <br /> I <br /> 'Telephone: ":'..(209). 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (32:g-:-Z. iE:5e-�.J ��t''c�0-r'�-_._._ (Complete, In Triplicate) <br /> Application ie-hereb made to the San Joaquin-Local.-Health District for permit to construct <br /> ,and/or install the work herein described. This, application is :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and. Regulations' of the San Joaquin ocal Health District. <br /> i t��t. <br /> Lzs C v�Ra..a <br /> JOE ADDRESS/LOCATION -� � QuZ o V ti - CENSUS TRACT <br /> Owner`s Name LO IG; Phone $- IOa <br /> Address Q� ga hadJ• 'T City '�SCZ <br /> Contractor's Name �,Q S c�• �C)� - License #o2W0ra PhonelCgJ212Jf <br /> TYPE OF WORK (Check): NEW WELL /- DEEPEN /-7- RECONDITION /-7 DESTRUCTION (7 1 <br /> PUMP INSTALLATION L_1 PUMP REPAIR /, PUMP REPLACEMENT I T w <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 <br /> Industrial Cable Tool Dia. of Well Excavation <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 <br /> ♦ Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State. Work.Done <br /> PUMP :REPAIR: State Work Done 02 <br /> -{ rJ' <br /> PP P <br /> pES;TRUCTION OF'WELL i��We11 Diarnetes— � �f A roximate Depth <br /> Desckibe Material aid 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 GRO TING AND FIML INSPECTION. ` <br /> SIGNED ,� TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> E2&4EPARTMAT USE ONLY t`.. <br /> PRASE I / f/ <br /> J APPLICATION ACCEPT Ivo�/��r/ DATE !/6 ` 76 <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA :UI/F AL ,INSPECT <br /> INSPECTION BY DATE INSPECTION ;Y�� DATE <br /> •,k <br /> E H 1426 Rev. 1-74 1-74 2M <br />