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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: -„ T - 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 Date Issued�7-L_ Z�t <br /> (Complete In Triplicate) <br /> Application is hereby made to the Salt Joaquin Local Health Aisttict 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.` 1$62 and Rules, d Re ulations•of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ._�- TZ7, 1 /C� CENSUS TRACT <br /> Owner's Name Phone <br /> Address .� . - - Cit • <br /> ( - .....�• _.,_,.,..,. y <br /> Contractor's Name 2LG�l,K License # Phone <br /> a 5 --/03/ ' <br /> TYPE OF WORD (Check) : INEW WELL DEEPEN RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /-7—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 6, PIT PRIVY <br /> SLWAGE`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 /,Z' <br /> Domestic/private , Drilled Dia. of Well Casing G S <br /> Domestic/public Driven z Gauge of Casing , <br /> -- - Irrigat�zrft�"`^" Grave Pack " Depth of Grout Seal `-p r <br /> Cathodic Protection � Rotary Type of Grout a 7--A, ' . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By.* <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump HOP. � .- <br />'E IN� <br /> PUMP REPLACEMENT: / / State Work Done 4C <br /> 42 <br /> t PUMP :REPAIR: ?_7 State Work Done <br /> u <br /> i ESIRUCTION OF WELL: Well Diameter <br /> 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 ofl[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 TOG OUTING AND h FINAL "SN ,ION. <br /> SIGNED k TITLE <br /> (MU PL LAN ON RSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I I� <br /> APPLICATION ACCEPTED-BYo " DATE <br /> ADDITIONAL COMMENTS: �. <br /> PHA E I GROUT INSPECTION . PHAS I F AL INSPECTIQN INSPECTION BY DATE _7, s;-' _ INSPECTION BY DATE n <br /> f <br /> 1-74 2M <br /> E H 1426 Rev. 1 74 <br />