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VSAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. >2-491_k! <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ ' . �;r <br /> �3 f� �Lrj�,•�'► � _-- - - � � .�� CENSUS TRACT <br /> Owner's Name oi� Phone <br /> Address City <br /> r <br /> Contractors NameA0, fi-_,r-MV&J" License I/ .7d&Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INST LATION 'jX PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD -- � CESSPOOL/SEEPAGE PIT��V ?`OTHER �- <br /> PROPERTY LINF/+� `PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL --�^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Z 2- <br /> Domestic/private <br /> Domestic/private _ Drilled Dia. of Well Casing �T^46 S/g <br /> Domestic/public Driven Gauge of Casing ! z2- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout Seal s do J`' <br /> Cathodic Protection At/ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface/Seal Installed By: <br /> PUMP INSTALLATION: Contractor r� <br /> Type. of Pump H.P'. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter C� / Appr xim to 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 knowl dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED E _ <br /> W PL T P ON RE RSE SIDE) <br /> OR DE TMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PILA,%E II OUT INSPECTIO P III/FINAL INSPEC 71PN <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br />