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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. ,, Stockton, Calif. <br /> Telephone: (203) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 6 -376[eJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 � �0 ,1"�/ ' 41t1� ,E'/�C! -rLL[L�4 , cue J CENSUS TRACT <br /> Owner's Name /, Phone 5 79-410 <br /> Address Q2Zr/f "'11 az CityA <br /> Contractor's Name J License �� p opia Phone ,522,:2 j1 <br /> cis f <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 Q • <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing aa <br /> _Z Irrigation �� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection g/ Rotary Type of Grout <br /> Disposal Other Other Information _ ` , _1� <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT 17 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 TOG OUTING AN A AL IN CT 0 .. <br /> SIGNED '[ _ (�. t ITLE <br /> aLzza <br /> (DMEELOT PLAN ON REV S E S ID <br /> OR DEPARTMENT US9 ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I IT INSPECTION PHASE jiVFINALWINSPECTION _ l <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 376 2M <br />