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.' - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 Jd ZY� <br /> • <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued R -/S 77 <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 /> JOB ADDRESS/LOCATION k' 3 J) A.,c� /,v /rJ CENSUS TRACT <br /> Owner`s Name 6=112012 Phone _ <br /> Addresso City __ <br /> Contractor's Name _-Z-0 License #/I <br /> hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /T<T <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 "0 <br /> Cathodic Protection Rotary Type of Grout \� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor g!�l -. <br /> Type of Pump _ s H.P. _- <br /> PUMP REPLACEMENT: State Work Done C-t' d1z 7"/1' A=$.,() <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 no ed e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO AND A FINAL INS TI <br /> SIGNED ITLE <br /> (DJAW OT L ON R E R S E SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY p DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> 01 7 <br /> 0, 77 <br /> E H 1426 Rev. - 1-74 <br /> . <br />