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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: ' (J� 1601 'E. Hazelton Ave. , ,Stockton, Calif. <br /> ,. Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2znA ul <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued <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 /> r-, County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3: (LOT <br /> JOB ADDRESS/LOCATION �V_t C <br /> -7 CENSUS TRACT <br /> Owner's Name E Phone �I"17 <br /> '-Address. R O B4� � City <br /> r <br /> _ r Licensej- 7 Phone �,.�`c�a <br /> =,', Contractor s Name <br /> ULU: wa, <br /> 11 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ./ / RECONDITION / / DESTRUCTION /_T <br /> x; PUMP INST LATION _/,_/ .PUMP -REPAI14/ / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PITS OTHER`` <br /> t; PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS („ <br /> sy Industrial Cable Tool Dia. of WeZI " Excavation' 1 <br /> Domestic/private Drilled Dia. of Well Casing ; <br /> Domestic/public Driven Gauge of Casing 3r/2- <br /> IrrigationGravel Pack Depth of Grout:, Seal ' <br /> Cathodic Protection Rotary Type of Grout 's / <br /> 1': Disposal ,c Other Other Information <br /> _! GeoP h y�sical Surface SealYInstalled By: <br /> _ y. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. '_ Y <br /> PUMP <br /> REPLACEMENT: / / State Work Done <br /> 'CaPUMP .REPAIR: i State Work Done <br /> ;.'DES-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 BAYS <br /> :`after completion of my work ona new well, I will furnish the San Joaquin Local Health District a <br /> N"HELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ;Qinformation„is. 'true -to,the:best of._my,.-knowledge and belief...._I.WILL_CALL FOR A. GROUT INSPECTION <br /> yPRIOR TO GROU NG ANDA INA N VEC710N. <br /> "SIGNED ' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ' <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;'.APPLICATION ACCEPTED BY� DATE <br /> ",ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE C. <br /> h <br /> 1/7.7 ' 2M <br /> :: E H 1426 Rev. 1-74 <br />