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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ L-2/ <br /> 40 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued� 23"7 <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 Rut sand Regulationsof the San Joaquin Local Health District. <br /> gyo / <br /> JOB ADDRESS/LOCATION SUS TRACT <br /> Owner's Name <br /> L� J A IV -- _ Phone 238-2337 <br /> Address <br /> City <br /> Contractor's Name ,p, License #c2Z�2ewy Phone <br /> 27i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_/ RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <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 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - -� State- Work Done 'G <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 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 GROUTIW AND A FINAL INSPECTION. y <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE UINSPECTION PHASEf II/F. AL INSPECTION., <br /> INSPECTION BY Al i_ DATE INSPECTION BY .; : DATE , <br /> E H 1426 Rev. 1-74 ' 1177 2M <br />