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SAN JOAQVIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :p (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. NM <br /> C THIS PERMIT EXPIRES 1 YEAR F <br /> ROM 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , f'4 <br /> •�-c !.c/ /CENSTIS TRACT -0-1.3- 22b-37 <br /> Owner's Name <br /> Phone � p-- 6d410 -2 <br /> Address _ / C'J. <br /> City <br /> Contractor's Name ® <br /> r License lllj ;�37.?Phone.2 A��?-Jd <br /> vii SC <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/ / RECONDITION /_/ DESTRUCTION-1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / " PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ITANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ! <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j 1 Cable Tool Dia. of Well Excavation d <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .j Gravel Pack Depth of Grout Seal 76 <br /> Cathodic Protection I X Rotary Type of Grout J 1 . <br /> Disposal " Other Other Informati on" — -- c <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:" Contractor ' <br /> Type onf Pump H.P. <br /> PUMP:.REPLACEMENT: > <br /> / / State Work Dane <br /> PUMP .REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL; Well Dameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> l <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' aboveinformation true to the best of. m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G IN AND A AL .INSP ION. <br /> SIGNED TITLE <br /> i WvnbiW- PWT PLAN OA� <br /> N REVERSE SI Z7 7!�, I: ; <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY �- DATE 7- ` �_7 <br /> ADDITIONAL COMMENTS: i - <br /> PHt <br /> AE4JI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / .21 INSPECTION BY DATE / , .7 <br /> --- <br /> E H 1426 Rev. 1=74 1 376 2M <br />