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r1 r'I <br /> (. ��r� •V / SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORrOFFIC (J 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466!-6781 <br /> { APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 Lmy)o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-&-2,2 <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 /> JOB ADDRESS/LOCATION aQ iz 4 Y !l C `/l.0 CENSUS TRACT <br /> T � <br /> Owner's ]!Tame J L /14, Phone <br /> Address _ 6P L] 40 e Ag:� City - .,... <br /> Contractor's Name License #dL2-&�X_Phone GL 7 6 <br /> TYPE OF WORK (Check): NEW WELL LV_ DEEPEN /7 RECONDITION /7 DESTRUCTION ff <br /> PUMP INSTALLATION 6.960 PUMP REPAIR 1-7 PUMP REPLACEMENT %f <br /> Other /-7 <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 Cable Tool Dia. of Well Excavation gv <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing O <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 INSiCALLATION: Contractor p„ - <br /> Type of Pump e. . t' H.P. <br /> ,,• <br /> PUNP REPLACEMENT: / / State Work Done <br /> PUIR /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 Saiz 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 INSPECTIO <br /> SIGNED _ ` E <br /> T <br /> DRAW ?AOT&IM POTON REV SIDE <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IMSPECTION P I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 777'�A <br /> t E H 1426 Rev. 1-74 1-74 2M <br />