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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-FOR,0EFFICEEUSE:-.E 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL 21 zel <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE *ISSUED Date Issued f37d i <br /> (Complete In Triplicate) <br /> A <br /> pplication is hereby made to! 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 andlthe Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '140q I"fN Cl'` <_ <br /> } <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> city Stn r� A/ <br /> Contractor's Name �_ fi Jl' FAL fQ 4111- License # 7 G,Z Phone 5/Gz-�L297 <br /> _ W <br /> TYPE OF WORK (Check): NEW WELL " DEEPEN •/? `RECONDITION _ f Z9� <br /> - /`f DESTRUCTION %f <br /> PUMP INSTALLATION /--/--PUMP REPAIR /-7 PUMP REPLACEMENT L-7 <br /> � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '� PIT PRIVY <br /> SEWAGE DISPOSP,T, FIELD <br /> CESSPOOL/SEEPAGE',IT._ OTHER <br /> PROPERTY' LINE - PRIVATE DOMESTIC�WELL' PUBLIC; DOMESTIC WELL <br /> INTENDED USE l'YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ation <br /> Irri <br />•--.�- g Gravel Pack Depth of Grout Seal. j <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal r Other Other Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of ;Pump H.P. , <br /> PUMP REPLACEMENT.— 2/T State Work Done <br /> PUMP .REPAIR: <br /> State Work Done <br /> r <br />]ES-TRUCTION OF WELL: ,Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E hereby agree to comply with all lawsand regulations of the San Joaquin Local Health District <br /> Ind 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 /> SELL DRILLERS REPORT of the well and notify them before putting. the_well. in.use...- .The above <br /> Lnformation is true to the-best-of my.-knowledge-and belief. I WILL CALL -FOR A -GROUT INSPECTION <br /> RIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> iIGNED l <br /> TITLE if&A } <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> �.. � � <br />►PPLICATION ACCEPTED BY DATE _/ Q <br />►DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />,NSPECTTON BY DATE INSPECTION BY DATE <br /> E_H.]426 Rev. 1-74 elm <br />