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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'2--Z;16J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lf"301 ? <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 Health District. <br /> IV <br /> JOB ADDRESS/LOCATION s4aD g CENSUS TRACT _ <br /> Owner's Name 013A 1013 Phone <br /> Address AS4LE l City �-Il?ej6z� <br /> Contractor's NameL losK t���ry � � (�, License 417-(¢ 2- Phone �.� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 _ <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a`r <br /> SEWAGE DISPOSAL FIELD 2'r 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 161, <br /> Domestic/private Drilled Dia, of Well Casing Gr, <br /> Domestic/public Driven Gauge of Casing (L <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection =Rotary Type of Grout L' <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 <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 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 r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY T <br /> PHASE I / <br /> APPLICATION ACCEPTED BY" DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION BY�-` DATE INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 <br /> 0/%7 <br />