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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: If/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> THIS PERMIT EXPIRES I 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s2 LL ��y1 - - CENSUS TRACT <br /> Owner's Name Phoney-v �/ <br /> AddressCity <br /> Contractor's Name �� V -� oA. ^T� License #C Phone " <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR A7 PUMP REPLACEMENT /- <br /> Other /7 T e t1_ <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 J"�Dep-th-of-Grou'r ea '-"—" <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 Dbne` <br /> PUMP .REPAIR: State Work Done; A.Q j2 , <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 t e best of my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUVNG AND A V <br /> /IN4LL INSPECTION. <br /> SIGNEDTITLE Z�. <br /> .i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E _ DATE ] ';77 <br /> ADDITIONAL COMMENTS: ' <br /> PHASF, I GROUT INSPECTION PHASE _ I/FINAL INSPECTION <br /> INSPECTION BY 111 ffDATE INSPECTION BY t DATE'S f `2 <br /> J '' , l <br /> E H 1426 Rev. 1-74 1177 2M <br />