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r 2v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FWfOFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 6 Aja <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anis/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 J n S T CENSUS TRACT <br /> Owner's Name V1 RGIL 6124 Phone �R- �a ....` <br /> Address _ ,) - City 6,204•L <br /> Contractor's Name Z. ,,...g License #*2 Phone <br /> DID <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '17 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP -INSTALLATION / PUMP REPAIR &? PUMP REPLACEMENT 17 <br /> Other /-TS Ev .�, <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 O <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 /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> LUMP :REPAIR: State Work Done! ° - <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Materia}: and Procedure <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 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 G TING AN A F NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -I3_ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-AIII&MW INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />