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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.ZLLV <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> � <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 yZllq E, .0,dRC/L/ X d. STOCKTO/l CENSUS TRACT <br /> Owner's Name 6-F—ORC.FE AROWN4EE Phone <br /> Address YLZ 11 F, AgcC q ,VQ. STOCK TON City TQekTQ/U <br /> Contractor's Name N0,,4ck ,001n,4 License #353-2/3 Phone 8-FF/17 <br /> TYPE OF WORK (Check) : NEW WELL §�' DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 601 SEWER LINES -t 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 /> — <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection x Rotary Type of Grout (ffA7- ,1 T,E <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Ala&Cit '144//y!100 <br /> PUMP INSTALLATION: Contractor `(/Q AC K wjpgdo <br /> Type of Pump _St/,9/"OERS/l&/ - 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 all laws and regulations of the San Joaquin Local HeA th District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAIS <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 GROUT NG AND,A FIML INSPECTION. <br /> SIGNED TITLE <br /> (DW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED B �- - DATE .349-;7ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO P E NAL INSPECTION <br /> INSPECTION BY �:IO DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 II R 2M <br />