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SAN JOAQUIN LOCAL HEALTH DISTRICT - --- <br /> FO$rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PaIP PERMIT Permit No. Al <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued -Z�- <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 P e5�32 CENSUS TRACT <br />. Owner's Name 2,QGa Phone <br /> Address 6 D�e--2 elIiZZ,C co City C22-6-14 I7� <br /> Contractor's Name License # 112-2L Phone j - 33 <br /> G 3 SC <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /'7 RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTAL TION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> -- i <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �V . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialble Tool Dia. of` Well Excavation <br /> Dome sti'd'/pr�,ivate '.' i Drilled Dia. of Well Casing � <br /> _ Domestic/public Driven Gauge of Casing Pa <br /> Irrigation Gravel Pack Depth of Grout Seal SCp_ <br /> Cathodic Protection Rotary .\Type of Grout &< (�r�Gi'1 <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '3-4 1g, H.P. <br /> PUNP:fREPLACEMENT: %/ State Woik Done s- <br /> PUMP.?REPAIR: / T- State Work Doone -- <br /> r <br /> ES;TRUCTION- OF WELL: Well Diameter Approximate Depth <br /> DOscribe Material and Procedure <br /> I hereby agree to comply with all lawsand..-regulations of the San Joaquin Local Health District <br /> and tike State of. California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion 'of my work on a fi6V--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 TD G OUTI G AND A FINAL. INSPECTION. <br /> SIGNED TITLE, , <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> --- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-:ACCEPTED-BY. '- DATE 7 <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION '' � '' .. PHASE TIT/FINAL INSPECTION <br /> INSPECTION BY DATE ,��% x INSPECTION BY DATE ,Zp <br /> E H 1426 Rev. 1-74 1-7r <br />