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fr+. 40 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> ZL APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2r3,VjP <br /> >--/V_7s- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-ir- <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 stealth District. <br /> JOB ADDRESS/LOCATION o� X" Ae rt T CENSUS TRACT <br /> Owner's Naas: ✓ �roJ 'v C_ Y.0 Phone <br /> Address 0-Z City <br /> Contractor's Name CG4 <br /> p^-----�, License # 4f Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN ,/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /7 PUMP REPAIR P_�7 PUMP REPLACEMENT % j <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t4 c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> t oK oe l V <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 kno ed d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FINAL INS CT V <br /> SIGNS ' _ .� TITLE <br /> ADRIW PT PLAN ON RVERSE SIDE*' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ZIL:l..�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAM I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � 7�-- <br /> E H 1426 Rev. 1-74 2M <br />