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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 0: 'vI'+. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. to f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ' off Z p , i G ,L. 2�i e/C li/y� 'CENSUS TRACT <br /> Owner's Name c �cTvytC G� .�GiY�OG �i S% Phone <br /> Address z /421e Yo 2/ w Cit <br /> Contractor's Name Gid /.J, ,r/px/ gyp_. License 4�a� Phone g- 4rq,9� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_% RECONDITION /-7 DESTRUCTION <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT <br /> AL /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 <br /> Domestic/public Driven Gauge of Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter /,a G.9 1416r Approximate Depth <br /> Describe Material and Procedure { 4 <br /> -d 7-0 O'A,) Ti/ Co IC.e.CTiE .r c-&7-0,9;C a a . <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to thebest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING D A FINAL INSPECTION. <br /> SIGNED TITLE A�) A,), ` ,& p <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1-2417� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAWZn1kfN@LL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /Z <br /> E H 1426 Rev. , 1-74 b/77 <br />