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SAN JOAQUIN LOCAL HEALTH DISTRICT O ,� <br /> F_0_R-7CI'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Sal<' ?,s 0/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 29 <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 ` �� Q Y ,� CENSUS TRACT <br /> '2 ` <br /> Owner's Name X _ '. Y � - Phone 14 �er2 <br /> Address 9,-Pm -e City <br /> Contractor's Name-.-S,e_/F w License # Phone <br /> TYPE OF WORK (Check):- NEW WELL/7 DEEPEN /_7 RECONDITION /—T DESTRUCTION <br /> + -PUMP-INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /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 /> E Industrial Cable Tool Dia, of-Well Excavation=- r <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 /> M Type of Pump .. H.P. <br /> � PUMP REPLACEMENT: ' <br /> / /"State Work 'e <br /> PUMP .REPAIR: / / -State- Work Done f <br /> E C( //� <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate Depth GfiY1,c <br /> De cribe tenial and Procedure Gv S'd•-� y� C� <br /> ftrm e s cr ,,­ a c-e Z� k <br /> I I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> M 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 puttingthe well in:use. . The above <br /> k information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAWLOP T PLAN ON REVERSE SIDE <br /> { FOR D PARTMENT USE ONLY <br /> I PHASE`I ' <br /> APPLICATION ACCEPT DATE 9 Z 3 -Zj� <br /> ( ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> E INSPECTION BY DATE INSPECTION BY DATE "- <br /> . . <br /> E H 1426 -"Rev. 1-74 !x/75 21J� <br />