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---G��? SAN JOAQUIN LOCAL HEALTH DISTRICT _._ �.... . <br /> FO;�rO FICE USE: 1601 E. H <br /> Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466_5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL-j2zwJo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATA ISSUED Date Issued 1 _S� <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 /> JOB ADDRESSAOCATION to S— _ L t C1t,3_,.. , L! CENSUS TRACT <br /> Owner's Name ! S Phone <br /> Address <br /> City <br /> Contractor's Name,} License # <br /> ��one 2_Of <br /> -7GaG <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/? RECONDITION /-7 DESTRUCTION %f <br /> PUMP INSTALLATION /_/ PUMP REPAIR � PUMP REPLACEMENT <br /> Other E/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ j <br /> ._ 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; Contractor r� <br /> Type of Pump H.P _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done G�1_ �,_ a,��.� y_. <br /> tea. <br /> ES TRUCTIQN 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.knowle a an elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U ING AND A FINAL INS ON. <br /> SIGNED <br /> TLE <br /> (D W LOT P ON REV E SIDE <br /> PHASE I <br /> 0 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: -• . <br /> PHASE II GROUT INSPECTION PHASE II F AL I PECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - I d - <br /> E H 1426 Rev. 1-74 <br /> _ 1-74 2M <br />