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Id SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: C.% 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7h- SbrC1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <br /> (Complete In Triplicate) <br /> Applicati i ereby 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 AOCATION _j Z 9_2 1- 4C-19 d cENsus TRACT <br /> Owner's Name WoL fat: h Phone 36 <br /> Address (f 4: /Q C A/4/20 R City A' C- a <br /> Contractor's Name fc'o�S1,641—1/c License #.2 $a Phone ZirC 9 2 S-- <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/7 RECONDITION lT DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR '/-7-pump REPLACEMENT 17 <br /> Other /� <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 X Cable Tool Dia. of Well Excavation /a <br /> X _ Domestic/private Drilled Dia. of Well Casing $`` �\ <br /> Domestic/public Driven Gauge of Casing / l" <br /> Irrigation Gravel Pack Depth of Grout Sealo <br /> Cathodic Protection Rotary Type of Grout �� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done N <br /> PUMP ,REPAIR: — <br /> /7 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 221 <br /> &*V*92 * TITLE F <br /> -�, <br /> RAW MT PLAN ON REVERSE SID —� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY ,•, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTXON <br /> INSPECTION BY DATE INSPECTION BY DATE/ <br /> E H 1426 Rev. 1-74 4/75 2M <br />