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_ C 'Ali .JOAQUIN LOCAL HEALTH DISTRI("f <br /> FOR OFFICE USE: 1 / 1601. F. 11azelton Ave. , Stockton, Callt. <br /> T+ilephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2_\2__ W <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued :�X 4 0 <br /> (Complete In Triplicate) t <br /> Application is hereby made to the San Joaquin Local Health District ft%r 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. 1t <br /> JOB ADDRESS/LOCATIGN � ��,, CENSUS TRACT f <br /> Owner's Name Phone ,36 l 190 / <br /> Address �� ._ hCp 2r4,:2i City .1.OAT <br /> Contractor's Name License !/1 Z,2 U Phone 9-33Y3 <br /> _r <br /> TYPE OF WORK (Check): NEW WELL M DEEPEN /7 RECONDITION /_T DESTRUCTION /7 <br /> PUMP INS'T'ALLATION /� ptw REPAIR L_7 PUMP REPLACEI"SNT j <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC,. TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMBSTIC WELL _._. J?UBLIC I HELL <br /> INTENDED USE TYPE OE WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Diu. of well Casing <br /> Domestic/public Driven Gauge of Casing � . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I: Cathodic Protection Rotary Typa of Grout <br /> Disposal Other _ Other Information f , <br /> Geophysical Surface Seal Installed B71 <br />-f PTTMP INSTALLATION., Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L7 State Work Done <br /> PLW :REPAIR: L7 State Work Done <br /> Ep S TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 bAYB <br /> after completion of my w)rk 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 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 GDOUTING ANDA FINAL 1?;SPECT ION. <br /> SIGNEDTITLE <br /> DRAW PLOT "LAN ON REVERSE SIDE <br /> r FLk DEPARTMENT USE ONLY <br /> PHASE I _ �] <br />■� /, DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> UM <br /> PHASE II GROUT INSPGCTToll PHASE III FINAL INSPECT <br /> INSPECTION BY DATE INSPECTION BY DATS <br /> E E 1426 Rev. 1-74 ` 1-74 2K <br />