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� I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOA,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) : 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � l _6 a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I—L -q <br /> ' (Complete In Triplicate) T7 <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 ADDRESS/LOCATION 0 d0 F_ S D, TOG o CENSUS TRACT p <br /> Owner's Name G 0 Phone _y62; `Z�r <br /> Address SAMECity /r/ <br /> Contractor's Name G License #,Zp_p7gy Phone <br /> 9�/fr R8l�7' <br /> i <br /> TYPE OF WORK (Check) : NEW WELLYT DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION R/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINESPIT 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 /> Domestic/private" Drilled Dia. of Well Casing H <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack. - Depth of Grout Seal <br /> Cathodic Protection )- Rotary Type of GroutAA1o T� <br /> .Disposal Other Other Information <br /> Geophysical' Surface Seal Installed By: AlGfC <br /> PUMP INSTALLATION: Contractor Q U c, <br /> Type of Pump U 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 DATS <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 GROUWXNG AND A FkVAL INSPECTION. <br /> SIGNED TITLE <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DE�_7NTUS_EONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B(�j DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S / INAL INSPECTI N �f <br /> INSPECTION BYTE 11-111- 7INSPECTION B DATE <br /> 7 <br /> ,y- <br /> E H 1426 Rev. I-74 r� 2A2 <br />