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f o ✓h �A °� �- 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 4�2 1-1-7 <br /> -- 22 (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. 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !t4,10, CENSUS TRACT <br /> r <br /> Owner's Name -} �►� �j Phone <br /> Address �- l �M City t 7 <br /> Contractor's Name,� <br /> , ,W <br /> 7tD /� G., ,'�;? r-- License # Phone k -7126 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR �/- PUMP REPLACEMENT <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 Cable Tool Dia. of Well Excavation <br />_t Domestic/private Drilled Dia, of Well Casing c� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ch <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type o f Pum <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ a <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Q <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 /> informati.on' s true to the best ofkn and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR- UTING D A FI IN CT N; <br /> SIGNEDkSE <br /> TITLE <br /> RAW PLOT PLAN ON RE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ DATE -12 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /-? //5IZ2 <br /> E H 1426 Rev. - 1-74 <br /> b,177 _ 2M <br />