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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ;. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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 2y 3 A��v x-7.0. CENSUS TRACT <br /> Owner's Name Phone <br /> Address `7'� ?,¢: 1 <br /> ��` � �Wit- �` City <br /> Contractor's Name ��� �- �✓ ejk/ ku r Aj p.�i�•P- cense # Phone <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN%/ RECONDITION__/ / DESTRUCTION /- _ <br /> PUMP INSTALLATION /� PUMP REPAIR /_/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK )&e_' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ..J-Zo_'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation -klp� jo <br /> Domestic/private Drilled Dia. of Well Casing 61: <br /> Domestic/public Driven Gauge of Casing 14C .is <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _X Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: zpjr�'N, <br /> X <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump ; H.P. <br /> PUMP REPLACEMENT: / / State Work Done `t <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 GRO ING AND A FINAL SPECTION. <br /> SIGNED TITLE V Rr%z.D 4)pz.9rioas <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F04 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A-Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ISI/FINAL INSPECTION ., <br /> INSPECTION BY DATE INSPECTION BY DATE J ;:_7- <br /> E H 1426 Rev. a1-74 n��7 - 2M <br />