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Cm ! SAN JOAQUIN LOCA. HEALTH DISTRICT <br /> FOa:OF: -CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2W_- 1,0 <br /> THIS PERMIT EXPIRES <br /> _ I YEAR FROM DATE ISSUED Date Issued 1Y_/S__ <br /> (Complete In. Triplicate) <br /> Application is hereby made tothe 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 CENSUS TRACT' <br /> Owner's Name Phone ' <br /> Address D �, <br /> ►�"' City 'y/ 7'dti <br /> `� 1 <br /> Contractor's Name F License r 2 C'Phnne -7 y <br /> TYPE OF WORK (Check): NEW WELL -L-7 DEEPEN / 7- RECONDITION /-7 DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other /% # <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL �n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,:* ... - Cable Tool Dia, of Well Excavation <br /> k Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public' 1 Driven Gauge of Casing <br /> Irrigation. . t . ° Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal .. Other Other Information `F•� <br /> Geophysical --------Surface Seal Installed 'B <br /> PUMP INSTALLATION:— Contractor <br /> Type .of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Donee t <br /> PUMP State Work Dane , <br />)ES1RUCTION OF WELL: Well DiameterApproximate 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 j <br /> after Completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'BELL DRILLERS REPORT of the we notify them before putting the..well. in use.. . .The above j <br /> Information is true to the,best-of- myand belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING 'AND A FINAL I1 CT N C <br /> iIGNED 4-g A) Z// �� � TITLE <br /> (DRAW PLOT PLAN O ✓REVERSE SIDE-� <br /> FOR DEPARTMENT USE ONLY <br />?BASE I <br />#PPLICATION ACCEPTED BY1411 <br /> DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 111 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426. Rev. 1-74 <br />