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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEIOF 'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit-No. 1 _33/4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued t�-f-2- <br /> (Complete <br /> r1(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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sax: Joaquin Local Health District. s <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> R <br /> Owner's Name Phone . ?1�P �- <br /> Address Z LdZog A Q City <br /> Contractor's Name <br /> License Phone�:�Z� 1 <br /> TYPE OF WORK (Check): NEW WELL /lf_ DEEPEN -/__7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ! , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESQ 4 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /da CESSPOOL/SEEPAGE PIT /fit d OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 7 /.able Tool Dia. of Well Excavation , <br /> domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �,,.e��► , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> X. ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done : . <br /> PUMP 'REPAIR: /7 State,Work Done <br /> PES TRUCTION -OF WELL: Well Diameters _ ,.. r Approximate Depth <br /> Describe Material and Procedure �..► <br /> . i � s <br /> I hereby agree to comply with all laws and regulations of�the Sail, Joaquin Local Health District <br /> and the State of California pertaining to or regulating weh construction. Within FIFTEEN DAYS i <br /> after completion of my work on a new well, I}will furnish <thewSan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before pu sting. 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 GWIN95MD A FIN SPECTION. i,• ` - - <br /> SIGNED % 4 -` W, �, , , - E� <br /> - w <br /> DRAW PLOT PLAN ON REVERSE`SIDE _ <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE G 6 <br /> ADDITIONAL COMMENTS: - — <br /> PRASE II GROUT INSPECTION PHASE 1II FINAL INSPECTION , <br /> INSPECTION BY DATE - "7,y INSPECTION BY DATE /,2-�$r-,7s- <br />�1 E H 1426 - T <br /> Rev. 1-74 1-74 2 <br />