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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOflrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6- 0'Y_-TP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LP -LZ__;2,6� <br /> E (Complete ln '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 rhe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION: f S . � i. CENSUS TRACT <br /> r <br /> Ownerp$ Name <br /> A V f/�/� Phone `� r <br /> Address A drl City - ZL,5Giakoj <br /> Contractor's Name "S"'4071 License G7 U0 Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR `/ PUMP,.REPLACD T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.,t 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 y E <br /> Domestic/public Driven Gauge of Casing �;-k " -N, '. <br /> Irrigation Gravel Pack Depth of Giout. .Seal�. - <br /> Cathodic Protection Rotary Type of Grout` <br /> Disposal Other Other Information' <br /> Geophysical. _ Surface Seal Installed By: -_-- <br /> PUMP INSTALLATION: Contractor <br /> i.ti Type_of_Pump H.P. s <br /> PUMP REPLACEMENT: .State Work Done c �S <br /> - <br /> PUNIP .REPAIR: /-7'_State Work"Dane <br /> RELTTRUCTIONJOF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 /> t' , <br /> after completion of my work on a new well, I will furnish the .San Joaquin Local Health District <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 F R A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A FINAL INSPECTION. <br /> SIGNED TITLE al <br /> U-? `K .; a (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' v` y *w t�W a ? ':F FOR.DEPARTMENT USE ONLY <br /> PHASE-, '.T,, <br /> I APPLICATIONA'ACCEPTED'BY z DATE Io •/ '] <br /> ADDITIONAL COMMENTS: <br /> PHASE"II ,GROUT INSPECTION PHAS I N INSPECTION <br /> INSPECTION,BY.` " DATE INSPECTION BY DATE - <br />+: t E H 1426 Rev. 1-74 1- 4 2M <br />