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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE LTSE: 4V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 Z2— id <br /> - <br /> a� <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 he in described. This application is made in compliance with San Joaquin <br /> Coun2DD <br /> d' RAT <br /> No. 862 n th ules and Regulations of the San Joaquin Local Health District. <br /> SS ION ¢� <br /> c. c, p/29 CENSUS TRACT <br /> Jas / <br /> Phone 3 7 6---4l a e <br /> Owner's Name r <br /> Address � U -L1_. City ��� <br /> r <br /> License # one 7 37 <br /> Contractor's Name 1 tA <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC DISPOSAI; F ELDWER LINE <br /> S PIT PRIVY SEWAGE CESSPOOL/SEEP GE PIT OTHER —ZVe <br /> ` PROPERTY LINEIWPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4,,-�able Tool Dia, of Well Excavation <br /> �amestic/private Drilled Dia, of Well Casing Z <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information b <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: —Contractor 16Sv-, Dr` W H.P. � S <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i 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 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. 1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN)P AL I PE ION. �. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 1r'` <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> DATE J <br /> INSPECTION BY DATE INSPECTION BY y _ <br /> 6/77 _ 2M <br /> E H 1426 Rev. , 1-74 <br />