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2 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR• flF"1G'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N0.17 = Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquii" <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> VV <br /> OB ADDRESS/LOCATION JY, J d -ri.. wC a Vd J_N i l w [� CENSUS 0 C1- 450-07 <br /> ,_. �`� TRACT <br /> Owner's Name o ✓ L d (f7. A _ Phone S L G a p C <br /> Address — A 2 4, 3 £ L^ E_ City AC 6J-LP a <br /> Contractor's Name 4-T— A, ILA- 2 License #/41323 PhoneG�'- 3 <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN '/-7 RECONDITION /? DESTRUCTION %f <br /> PUMP INSTALLATION 'e /PUMP REPAIR / PUMP REPLACEMENT <br /> Other /'/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <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 �r <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 Groutm <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed_B : <br /> PIMP INSTALLATION: Contractor <br /> � nn <br /> Type of Pump H.P. / <br /> PUMP EN <br /> REPLACEMT: <br /> _ - / IT 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 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 tr4ie to the-best of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT A FINAL, IN CTION. <br /> SIGNED TITLE1 <br /> DRAW PLOT PLAN ON REVERSE SIDE) A, <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: = ',.. .. <br /> PHASE II GROUT INSPECTION PHASE ILL FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />� E H 1426 Rev. 1-74 <br /> - 1-74 2M <br />