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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFEICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 1f.?_ -7SY <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with ISan Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r r 2. - 220 <br /> JOB ADDRESS/LOCATION ' *, %tea CENSUS TRACT <br /> Owner's Name <br /> Phoned -� �C� <br /> r. <br /> Address � G ,�/p�s.��=tti-`C ,. �. City ` c�G.� _. . <br /> Contractor's Name `l'r�/{= ,l/� LicenseGa ,7W-Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN -J-7 RECONDITION /_7 DESTRUCTION l <br /> PUMP INSTALLATION f <br /> PUMP REPAIR I / PUMP REPLACEMENT f7N <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 /> !j�_ 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 s'-p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed-By: <br /> : <br /> PUMP INSTALLATION: Contractor �� » <br /> Type of Pump � . H.P;.,.�.`_ t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 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 k on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT f th well and notify them before putting thewell i -use.. The above <br /> information is my know ge and belief. I WILL CAI, QIP A GROUT INSPECTION <br /> PRIOR TO NAL I SP IQ . <br /> SIGNED '-i��C� TITLE �% <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ! 2- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: (/11 y <br /> PHASE I GROUT INSPECTION PHASE I I/ NAL INSPEC N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ( �Zr`�' 3►'t t '�. f C l.� 1-74 2M <br />