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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E9$ OFFICE USE: 1601_ E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,,2 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 7� <br /> (Complete In Triplicate) <br /> Application is Aereby 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 CENSUS TRACT <br /> Owner's Name Phone ,Z - <br /> Address 2la,,L City <br /> Contractor's Name �+n�E , j�f���� �il� � L License 1�3,jJUJy_ Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/ / (EE�PPEN f RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLAT _ UMP REPAIR / / PUMP REPLACEMENT /� V <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSO `f SEWER LINES 114 PIT PRIVY SA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER — <br /> PROPERTY LINFIL!4PRIVATE DOMESTIC WELT !_4 PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � y Cable Tool Dia. of' Well Excavation R ' <br /> Domestic/private Drilled Dia, of Well Casing '+ i <br /> Domestic/public Driven Gauge of Casing , 4-s-- y _. <br /> Irrigation Gravel Pack Depth of Grout Seal UV 159971 <br /> Cathodic Protection Rotary _ Type of Grout <br /> Disposal Other Other InformationX� ���€{r,�rq <br /> Geophysical Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 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 Aest of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING A FIJAL SP 0 <br /> SIGNED TITLE E <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE �Z• <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE ATE W_Ldalr <br /> '1177 <br /> E H 1426 Rev. 1-74 <br />