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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrO FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� b5�4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2�S 7q- <br /> .a . (Complete In Triplicate) <br /> Appliciation 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 4:s, nl � a2 CENSUS TRACT <br /> Owner's Name 2 ,.tea Phone � � 2ys5Z- ! <br /> � I <br /> Address "` c� City _2!&5C44,d <br /> Contractor's Name !� � z5'�� License # Phone <br /> TYPE .OF WORK .(Csheck).- NEW WELL -/7 DEEPEN /? RECONDITION /? DESTRUCTION (7 <br /> PUMP-I-NSTALLATION / / PUMP REPAIR gr­PUMP REPLACEMENT /7 <br /> Othet <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT. ' " #PUBLIC DOMESTIC WELL S y <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 <br /> Cathodic Protection- Rotary Type of Grout <br /> Disposal Other other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: , ,,{ Contiactor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-"PUMP''REPAIR: —State-Work,Done _ ! T - •-y, r <br /> . 4ES TRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> I- I hereby agree to comply with all .laws and regulations of the San Joaquin Local. Health District <br />�. <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 FOIVA GROUT INSPECTION <br /> PRIOR TO GROUT G OD A F AL INSPECTION. <br /> SIGNED TITLE Zg:�&E ) <br /> f�MW PLOT PLAN ON REVERSE SID <br /> < FOR DEPARTMENT USE ONLY <br /> PHASE I 6 <br /> APPLICATION ACCEPTED BY AATE fTl�r <br /> " .ADDITIONAL COMMENTS: k <br /> PHASE.ILLNSPE ON I AL INSPECT <br /> .: ..INSPECTION BY V DATE INSPECTI N BY DATE -Z _ <br /> `R. ~E H 1426 Rev. 1-74 <br />