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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E0t OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � Telephone: (209) 466-6781 <br /> 1IAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2z--'ice <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 Joaquit <br /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> it <br /> JOB ADDRESS/LOCATION f �.C? /�q/jwf� �/�n.{ CENSUS TRACT <br /> Owner's Name t ', Z;l Kil - - - Phone 3012- -7W Z_,d <br /> Address 2313 Kff tv1 h VC . :. City <br /> Contractor's Name <br /> License # rPhone -- <br /> i <br /> TYPE OF WORK (Check) : INEW WELL/ DEEPEN '/ / RECONDITION / / DESTRUCTION /� <br /> _ REPAIR / / PUMP REPLACEMENT /� <br /> IlPUMP TNSTALLAT Other <br /> it <br /> DISTANCE TO NEAREST: SEPTIC TANK -laSEWER LINEPIT PRIVY <br /> SEWAGE DISPOSAL S FIELD CESSPOOL/SEEPAGE PIT OTHER ,11 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ` , TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> IndustrialI 1 Cable Tool Dia. of Well Excavation /;U <br /> �r Domestic/private) Drilled Dia. of Well Casing f. rQ ' <br /> Domestic/public Driven Gduge of'Casing <br /> Irrigation t , €Gravel Pik Depth of Grout Seal <br /> \` Type of Grout <br /> Cathodic Frotect�on '"""�` 'Rotary- w ----.M yp <br /> ` 3 Disposal , Other Other Information'` <br /> Geophysical i Surface Seal Installed By:-Aacsy '00,i/"M, <br /> ( PUMP INSTALLATION: 1,i'Contract <br /> IJ <br /> ' Type of Pump <br /> PUMP REPLACEMENT: �i/ / State Work .Done <br /> PUMP�,.REPAIR: 7/ State Wprk ,Done <br /> DESTRUCTION OF ,WELL: <br /> 'Well Diameter ra. ' Approximate Depth <br /> ° <br /> IlDescribe Material and Proced'u're ; <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 we ll:construction. Within FIFTEEN DAYS <br /> after completion)sp.f mytworkon anew well,TI will 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.1the best of. my knowledge and belief. I WILL CALL FOR A GROUT''INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ; SIGNED 4 TITLE <br /> it <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> ..PHASE I <br /> i APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION �i <br /> INSPECTION BY DATE . INSPECTION BY. DATE <br /> E H 1426 Rev. 1-74 177 <br />