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i�' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;. Z�a6 3zd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date j4sued 3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for -a �ziitto construct <br /> and/or install the work rein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18 2 nd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - - zS,(cI. CENSUS TRACT <br /> Owner's Name Qimioj, Phone <br /> Address aolx Lurntil, City A/' 4� <br /> Contractor's Name License # a DJV/3 Phone 5W-/,03/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN / / RECONDITION /—[ DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -bop WER LINES PIT PRIVY aWjGAUC0-UCruw <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT418R r1P4F41V4F <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 7 ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 " <br /> Domestic/private Drilled Dia. of Well Casing (A <br /> Domestic/public Driven Gauge of Casing /yaCL, <br /> o� <br /> Irrigation _�/ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _�� Rotary Type of Grout — Q <br /> Disposal Other Other InformationCPQ f�i.Aint <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP,REPLACEMENT: / / State Work Done <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 a laws d regu ti s f an Joaquin Local Health District <br /> and the State of California rt ning ;� or reg n % w l construction. Within FIFTEEN DAYS <br /> after completion of my work n aTd <br /> w we I it is the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the ell no i them e e putting thewellin use. The above <br /> information is true to the b st of my-k` edge a d be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING ANDA YIN IN ECTI <br /> SIGNED ITLE <br /> D LAN ON RE SE SIDE) <br /> FOR DEPARTMENT USI ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION IVDATE <br /> E H 1426 Rev. 1-74 7 7� <br />