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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0WZFFICE;.USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,1=/'Z,0 4'. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED :'Date Issued _ -� <br /> (Complete In Triplicate) -`ago -d'2— <br /> Application <br /> dvApplication is hereby made to the San Joaquin Local Health District for permit 'to -con_ sttuct' # <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 SatiJoaquin LocaV Health District; <br /> tf S C s 2u.J � <br /> JOB ADDRESS/Y,OCATION (_J�"C�c�` r _�,+ SUs TRACT' <br /> 01 <br /> Owner's Name 0Phone 967 } <br /> rn <br /> Address City � �� .z� <br /> Contractor's Name 44 License #,?j22,Zf4, Phone 06 h <br /> o� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 9 <br /> PUMP INSTAL TION PUMP REPAIR /7—pump REPLACEMENT /7 <br /> Other <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 'Z _ <br /> _'-Dlomstic/public Driven Gauge of Casing cr <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal , Other Other Information' <br /> Geophysical Surface Seal Installed By-.- <br /> PUMP <br /> y:PUMP INSTALLATION: Contractor A 1-o!c_c <br /> Type of Pump r'h�i� �� -,�... I .P. aS <br /> PUMP REPLACEMENT: / / State Work Done <br /> t 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 w on a new well, I will furnish the San Joaquin Local Health District e <br /> WELL DRILLERS REPORT the well and notify them before putting the- well- in use. The- above <br /> information is a est my ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AND INa IN E <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ` z <br /> k ADDITIONAL COMMENTS: VQ AA-0 ! <br /> PHASE II GROUT INSPECTION PHASE IIIFINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE , /7 6' <br /> ,! E H 1426 Rev. 1-74 1-74 9M 1` <br />