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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi: CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2 //fes <br /> , � permit <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> � (Complete In Triplicate), <br /> Appiicetio-Q tereby made to the San Joaquin Local Health District fora 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 off theSanJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION cS4K N1 �r9Y`"�� .,4�tr r 7/ o4 CENSUS TRACT <br /> Owner's Name Aga Phone <br /> Address <br /> L<-"' ,Q City Cir }.,o <br /> Contractor's Name License # Phone 42: '" <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/ 7 RECONDITION / DESTRUCTION f7 <br /> PUMP INSTALLATION /—/­PUMP REPAIR 1-7—PUMP REPLACEMENT / <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X 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: Contractor T �. <br /> Type of Pump -, H.P. <br /> PUMP REPLACEMENT: &/ 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 DAYka after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 ofm knowled belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOGROUTING AND A FINAL IN CT . <br /> SIGNED(-'.NIle, TITLE <br /> m ;�t C <br /> LO P ON FRSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> az <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION BY FDATE INSPECTION BY z DAT <br /> E H 1426 Rev. 1-74 2M <br />