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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZS 2.) -0 <br /> THIS PERMIT ,EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z <br /> (Complete In Triplicate) (^73_,02X-- 2-(- <br /> ' <br /> Application is hereby made to the San Joaquin Local Health District . <br /> for a permit to construct 3 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and then es and Regulations o t San Joaqu� al Health District.. <br /> r atons �- x-4633 �� � _ <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name Phone yG . <br /> Address city <br /> Contractor's NameLicense # IGGa2 PhAe-z- ILLane � ` <br /> TYPE OF WORK (Check): NEW WELL . DEEPEN /7 RECONDITION /-7DESTRUCTION %J <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT %7 I <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL YIELD CESSPOOL/SEEPAGE PIT OTHER S <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N <br /> Domestic/private Drilled Dia. of Well Casing — <br /> i <br /> Domestic/public Driven Gauge of Casing / (%! <br /> Irrigation Gravel Pack Depth of Grout Seal `Y <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 Done <br /> PUMP ,.REPAIR: /7 State. Work Done 4 <br /> ES;TRUCTION OF WELL: Well Diameter Approximate -Depth <br /> Describe Material and Procedure f <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 Vi11 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 knowledge.-and belief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR T"ROUTIbYG AND A FIUL MSPE <br /> SIGNED ( TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION ACCEPTED BY al-wt DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY =1i , DATE . INSPECTION BY DATE <br /> 7,i 3yjp <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />