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_ L/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF *OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-��9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedl-7, <br /> (Complete In Triplicate) 21f7-300-f7 <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 /> 0 A WWOW )1c D c am ' / Da-&rrw <br /> JOB ADDRESS/LOCATION .� k . IYV- CENSUS TRACT <br /> Owner's Name n d` ; Phone <br /> Address _$ 1 �S �es-t t ra� City <br /> Contractor's Name k) MOO (% Licef e­# hone,59g-31(S7�, <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DE ON /-7 <br /> PUMP INSTALLATION/J'/ PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLC� <br /> INTENDED USE o TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled pia. of Well Casing <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 /> PUMP INSTALLATION: Contractor h)yLS' �2 <br /> Type of Pump ts� - _..__._._ H.P. <br /> . PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESS 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 _ r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Lk-DL&J') <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS /YfNAT, INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE J-12 <br />,.,�. <br /> E H 1426 Rev. 1-74 1177 _ 2M <br />