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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22-2j Zk) <br /> 77 �rf6� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 2__2,C__7_7 <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. 18)62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A li� CENSUS TRACT <br /> - . <br /> Owner's Name Q-1-1 12n C, Phone <br /> Address3)3 �C� �` . `)- C city <br /> Contractor's Name d lu I� $ (3 rtn License # )3Cc 3 Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -/`f RECONDITION /-7 DESTRUCTION f-7 <br /> PUMP INSTALLATION PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _3()U SEWER LINES • PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD _30.0' CESSPOOL/SEEP�GE PIT -•-�- OTHER ..--- <br /> PROPERTY LINE �- PRIVATE DOMESTIC WELL Z PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation :�.0 <br /> Domestic/private Drilled Dia. of Well Casing9. <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: /9�1 <br /> PUMP INSTALLATION: Contractor cc! , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <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 DRILLERSREP T of the well and notify them before putting. the.-well- in use.. The above <br /> informationAtIG) <br /> r e1- to the-best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G iAD A FINAL INSPECTION. <br /> SIGNED i , . TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE " <br /> ADDITIONAL COMMENTS: -.4,-,��- . . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />