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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;4FI'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. el 5-16zd <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 /> .FOB ADDRESS/LOCATION S CENSUS TRACT <br /> Owner's Name Ap Phone —531 'x`—�.S jA_1_ <br /> Address � � �'D � d:nu <br /> --ter <br /> City . addo <br /> Contractor's Name <br /> License # 6 Phone <br /> TYPE OF WORK (Check) : -NEW WELL / DEEPEN/? RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTAL TION / / PUMP REPAIR '1_7 PUMP REPLACEMENT /T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PTT PRIVY <br /> SEWAGE DISPOSAL, FIELD CE SS POOL/SEEPAGE 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 <br /> Domestic/private Drilled Dia: of Well Casing j,51 QUIMZZa <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel-Pack- �. Aepth of Grout Seal <br /> Cathodic Protection RotaryType of Grout [� <br /> Disposal - Other Other Information <br /> Geophysical � � "�""�"'�" <br /> Surface Seal Installed By: 4s a <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . J-7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> E&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 anew well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before-putting.the..wel.l. 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 2n,22-7e, <br /> ADDITIONAL COMMENTS: <br /> P II UT NSPECTION P III INAL INSPECTIPN <br /> 11, <br /> INSPECTION B ATE Z, INSPECTION BY DATE -3 <br /> 1� <br /> CIL <br /> 2s2 <br /> E H 1426 Rev. 1-74/bj r Cadts+,1 r x/75 2M <br />