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SAN JOAQUIN LOCAL HEAi�TH DISTRICT <br /> FOSrOFFICE USE: 1601 E. Hazelton Avd: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !(_ 8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2--2 7-Jy <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. <br /> JOB ADDRESS/LOCATION�ZdIbRlDGE RD =NEAR AUGUSTA ST-20ACRE PARCEL <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address City QQNOQRD �- <br /> Contractor's Name NNTNr,,S RRoS„ TIRTTj_ aSp �TNC License.# 16,A Phone X22-564 <br /> 2K <br /> TYPE OF WORK (Check) : NEW WELL /%T DEEPEN J7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR 1_7 PUMP REPLACEMENT F7 <br /> Other /7 <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 ,2 Ori <br /> Domestic/private Drilled Dia. of Well Casing 121f <br /> Domestic/public Driven Gauge of Casing V16 GA <br /> Irrigation Gravel Pack Depth of Grout Seal _fin t -- ---'�" <br /> Cathodic Protection ^ Rotary Type of Grout CEMRNJI <br /> Disposal Other Other Information ST,AR_ 'BY QWW.R <br /> Geophysical Surface Seal-.Installed By: CONTRACTOR -' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 3 _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: L-7 State Work Done <br /> ES•TRUCTTON OF 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 /> 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 FINAV INSPECTION. <br /> SIGNED % TITLE <br /> RA OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B } DATE Z - <br /> ADDITIONAL COMMENTS: <br /> -PHASE IT GROUT INSPEC ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 2Z. INSPECTION BY — .._ DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br /> _, <br />