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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,,OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2zl <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 tfealth 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 1Z7j9 e. - 4 C° r CENSUS TRACT <br /> Owner's Namea 2 ne 2 i <br /> i <br /> Address 1770L X" / � . ' city <br /> Contractor's Name License # .qgo Phone <br /> TYPE OF WORK (Check): NEW WELL 17K DEEPEN /-7 RECONDITION /-' DESTRUCTION f7 <br /> PUMP INSTALLATION / f PUMP REPAIR /-7 PUMP REPLACEMENT / <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK C ' SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <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 /> k_ Domestic/private Drilled Dia. of Well Casing tV <br /> V« <br /> Domestic/public Driven Gauge of Casing /, 4-51y <br /> Irrigation Gravel Pack Depth of Grout Seal 15n-# <br /> Cathodic Protection _� Rotary Type. of Grout <br /> Disposal Other Other Information ISM <br /> Geophysical Surface Seal Installed BY: _ 1 <br /> PUMP INSTALLATION: ContractorZ: <br /> �..1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /? State Work Done <br /> ES�TRUCTION 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 A FINAL INS ECTION. <br /> SIGNEDITLE <br /> (DRAW ZLOT PLAN ON REVR9SE SID <br /> ;44= <br /> USE y1 <br /> PHASE I �d <br /> APPLICATION ACCEPTED BY , DATE 7 Z/- <br /> ADDITIONAL COMMENTS: <br /> P GROUT INSPE TION n' P111I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY`(:SAjJjv,, DATE - 9-5 <br /> 4„ <br /> E H 1426 Rev. 1-74 1-74 2M <br />