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SAN JOAQUIN LOCAL `HEALTH DISTRICT <br /> FORi.OFFICE USE: 1601 E. Hazelton.Ave. ; Stockton, Calif. <br /> Telephone: ! (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g- <br /> THIS PERMIT EXPIRES 1, YEAR -PROM DATE ISSUED Date Issued 2:_2_4-_7X <br /> (,Complete .,.In,Triplicate) . <br /> Application is hereby made to the San Joaquin, Local .Ilealth 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. <br /> JOB ADDRESS/LOCATION :, K: : CENSUS TRACT <br /> Owner's Name 6z lqza F Phone P;5_- s',! <br /> Address,.. <br /> City <br /> Contractor's Name 222al4w License Phone <br /> TYPE .OF WORK .(Check): NEW WELL ./V/ DEEPEN T7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /, / PUMP REPAIR /_7 PUMPF REPLACEMENT 17 i <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK �f:! V 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 12= <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection J! Rotary Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed By: :+ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work'Done- ~ ' <br /> PUMP 'REPAIR; /_7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter. . Approximate Depth � r2 <br /> Describe Material and 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 GROUTING AND A FIN IN PECTION. <br /> SIGNED - <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY j <br /> �� <br /> ADDITIONAL COMMENTS. DATE <br /> � �-- <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 a_7G int <br />