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r SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> FOOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Tom=/3G W i <br /> S 1 S91'O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue -7_2-T-r <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/LOCATION Z © CENSUS TRACT <br /> Owner's Name 60iLa.C1LlC_ conlal 9:12 Phone iss9 - zos`l } <br /> Address 2 ~7 d YO IV �i�.��-Q_ 919911-21-=& City I, <br /> Contractor's Name License_ Phone 6 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN 17 RECONDITION /uT DESTRUCTION /7 <br /> PUMP INSTALLATION X/ PUMP REPAIR / / PUMP REPLACEMENT 1_7 4 <br /> Other <br /> V` <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 <br /> Domestic/public tiDriven Gauge of Casing .1a , <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 INSTALLATION: Contractor (7" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP '.REPAIR: / f State Work Done <br /> ,pESTRUCTION 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 <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 TO GROUTING AND A FINAL INSPECTION. -- <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE BY � � DATE ZZ <br /> ADDITIONAL CO <br /> • ROUT INSPECT OM P II3AL INSPECTIO _ <br /> INSPECTI BY DATE —/P INSPECTI DATE <br /> E H 1426 _ Rev. 1-74 1-74 2M <br />