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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued aez--Zqy <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 Rules and Regulations of the San Joaquin. Local Health District. <br /> 316r�, <br /> JOB ADDRESS/LOCATION ' Al d �� CENSUS TRACT <br /> Owner's Name _ �/ WzArr — ---- Phone <br /> Address K" ?" In& -zinLeew City <br /> Contractor's Name - License #�j Phone .62 a r <br /> ASMAW6 B-99119 <br /> F <br /> TYPE OF WORK (Check): NEW WELL I DEEPEN/_-7 RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f7 <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 6 4 Cllj <br /> Domestic/private Drilled Dia. of Well Casing 16 9* ••w- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal V 4 <br /> Cathodic Protection Rotary Type of Grout jv h// <br /> Disposal Other Other Information __j, ,4 IV.eM <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump 4 H.P. ! <br /> PUMP REPLACEMENT: l�l State Work Done <br /> PUMP '.REPAIR: �- /� -State-Work Done <br /> ,RES 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 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 GRO ING AN A INSPECTION. <br />'F SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S14E) :20L a aro <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL coMmgqK- <br /> PHW GROUT INSPEC ION Py&H I INAL INSPECT- N <br /> INSPECTI DATE - iNSPECTI BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />