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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2d44-f <br /> 710 a lip <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 Health District for a permit to construct <br /> and/or install the work herein described. This application is grade in compliance with San Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.,, <br /> JOB ADDRESS/LOCATION <br /> _.. ,. ,���/�%�-� �, CENSUS TRACT r - <br /> Owner's Nance !/ � Phone , "r 77 � <br /> Address %� City ' <br /> Contractor's Name AS W A License #2 q Phone 7 z <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/7 RECONDITION I-T DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT l f 1 <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 Ga <br /> Domestic/private ,Drilled Dia. of Well Casing <br /> 42 I <br /> Domestic/public Driven Gauge of Casing /d F <br /> Irrigation �...:_ .__._� :- .._..� ...- Gravel-Pack- - Depth -,of Grout .Seal <br /> Cathodic Protection_ Rotary,_ .__.,_ y._Typerof Grout-- <br /> Disposal b. Other Other Information <br /> Geophysical Surface Seal Installed BE:.- ,,- <br /> PUMP INSTALLATION: Contractor <br /> �GS7f r <br /> Type .of Pump ,H.P• <br /> PUNP 'REPLACEMENT: • / / State Work Donee <br /> PUMP .REPAIRt _ / "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 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 AND A FINAL INSPECTION. <br /> SIGNEDTITLE. <br /> DRA PLOT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �.� 7-6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ; . PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> E'H 1426 Rev. 1-74 4 - 4/75. 21''I: � <br />