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SAN JOA UIN LOCAL CAL HEALTH DISTRICT <br /> FOROLFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z 4S/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,-a 9 <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 /> / / a <br /> JOB ADDRESS/LOCATION , '` ,�/1,/ S d�/�r �l./as oortrltsUS TRACT <br /> Owner's Name Phone <br /> Address 27 G I/ �y City to A-%.�.._.._ <br /> Contractor's Name rJ0 A License # / hone L?G <br /> Lor <br /> TYPE OF WORK (Check): NEW WELL / j DEEPEN /7 RECONDITION / DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other Z-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER �U <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 />__�C 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 <br /> Type of Pump H.P. 3?J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done efA�,�, ,a, `aa�/- *,o 6 *1 Le A4.) /0Cla 7`r 40 <br /> Or <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 knowledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL PE N. 9 <br /> SIGNED TLE <br /> (DjjAtAW PLO PLAN ONRSE SIDE <br /> FOR DEPA4TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE A 3- 7,/a <br /> ADDITIONAL COMMENT Ss <br /> PHASE II NS CTION F E I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7Lo <br /> E H 1426 Rev. 1-74 2M <br />