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SAN JOAQUIN LOCAL ,HEALTH. DISTRICT <br /> i, <br /> 1601 E. Hazelton Ave. , Stockton, Calif. " <br /> Telephone: (209} ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 <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/LOCATIONAll AtV �{ CENSUS TRACT <br /> Owner's Name 1419, A-1 Phone I !_Lam / <br /> Address AlCity +� oc <br /> Contractor's NameAeM4�6.._ t License # Phone <br /> S <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> -PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK' -'-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE-S-SPOOL/-S-EEPAGE-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 2 ' <br /> Domestic/private Drilled--z Dia. of Well Casing _ /? " W <br /> Dome stic/publ:ic._ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal VV --�-- <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other`Information <br /> Geophysical Surface ;Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of'-Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />_PUM?':REPA:IR--7 StateWork Ddne <br /> DESTRUCTION 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 Jbaquin 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 a <br /> information is true to the best of y .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING MD A F N I ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR EPARTMENT USE ONLY, <br /> PHASE I <br /> APPLICATION ACCEPTED BYdt /dN DATE " a <br /> I <br /> W-7-7 <br /> 1ADDITIONAL COMMENTS: <br /> PHAS'E'II GROUT 'INSPE_TION PHASE IIJ FINAL INSPECTION 1 <br /> 'ECTION BY . nNlp.� DATE INSPECTION BY DATE <br /> � <br /> `!\1L/ <br /> �ti n- <br /> 1 „ 1/77: -- E'12M t t <br />