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AN JOAQUIN LOCAL HEALTH DISTRICT <br />` FflArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 9i610 <br /> THIS PERMIT EXPIRES ,1 YEAR FROM DATE ISSUED Date Issuedza.51-7-1 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> he install or <br /> and <br /> / t work herein described. This application is made in compliance with San Joaquin <br /> Count Ordinance No <br /> County 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONs2 Q AiL- 1,ZL 00, CENSUS TRACT <br /> Owner's Name p Phone �a --; a <br /> Address A vn L City (0fir' , <br /> yj t'c <br /> Contractor's Name '� ,,� ,,) License _2941_20 i t�Phone <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION f-7 <br /> PUMP INSTALLATION �0 PUNP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Industrial Cable Tool w Dia, of Well Excavation <br /> Domestic/private Drilled Dia. 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 -(,A4,Jj,/ _ -- - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /% 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 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 ANDCA)FINAL. INSPECTION. <br /> SIGNED el TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> EPART T USE ONLY <br /> PHASE I FWM <br /> APPLICATION ACC TEA BY '11-11V67 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION $Y DATE <br /> 's E H 1426 Rev. 1•-74 1-74 2M <br />