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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOVOFFICE USE: 1.601 E. Hazelt6c Ave- , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�;21Y374j <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 /> ZU IJ • 14 C,-A Tr � D?3 T cos o Co 6 <br /> JOB ADDRESS/LOCATION �" L L2-a a I tVS 1-9 CENSUS TRACT <br /> Owner e s Name 4q la,�Lv.'L:j �(i Phone -3 <br /> Address At 1 City L; EV 0 k A <br /> Contractor's Name ¢b License # Q <br /> y Phone <br /> `5 <br /> _ S�3Y7 <br /> TYPE OF WORK (Check): NEW WELL M7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP- INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Ido 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 Drilled1 Dia. of Well Casing 19 coryl�d c-7Q ��1��t`L�- <br /> Domestic/public Driven" "` Gauge of Casing ! e <br /> Irrigation, Gravel Paek Depth of Grout Seal ..+5--a 4­ <br /> Cathodic Protection Rotary Type of Grout (I P-44_F N I- W <br /> Disposal _ Other Other Information <br /> Geophysical" Surface Seal Installed BY: jyjj4f.ZL PI/ lA <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done - <br />} PUMP :REPAIR: q7 State-_Wolk Dohe <br /> i <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE _k <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 2, DATE <br /> ADDITIONAL COMMENTS: <br /> SE I ROUT INSPECTION ti P I I NAL INSP IO <br /> INSPECTION BYE DATE INSPECTION BY AAT c� <br /> v <br /> E H 1426 Rev. 1-74 �. 1-74 2M <br />