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SAN JOAQUIN LOCAL 14EALTH DISTRICT <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION ICOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -.2�F�J�' <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 /> JOB ADDRESS/LOCATION W, a-•-xa CENSUS TRACT Ot_? - NO O-tj <br /> Owner's Name Phone (� � S 5!1 z <br /> Address �Ko t a/ 1, -xL CityLzz4 <br /> Contractor's Name License #A.1373 Phone 3 J .3 <br /> TYPE OF WORK (Check): NEW WELL /-74DEEPEN /-7 RECONDITION /7 DESTRUCTION f_7 <br /> } PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT % J <br /> AL <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 "v . _ CONSTRUCTION SPECIFICATIONS <br /> Industrial r - Cable Tool �� 2 Dia.M of Well Excavation <br /> Domestic/private Drilled Dia., of Well Casing <br /> Domestic/public Driven Gauge-of, Casing <br /> Irrigation Gravel Pack , Depthmof Grout Seal <br /> Cathodic Protection Rotary Type of� Grout� - - . <br /> Disposal Other /.Other-Information <br /> Geophysical T ;Surface Seal-Installed By., <br /> PUMP: INSTALLATION: ContractorU f <br /> - Type of Pump t �' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPt,REPAxR: - .Styato <br /> Work-Donelc.C:C <br /> es <br /> ' WelApproximate Depth ESTRUCTION m <br /> 4 <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f 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 GROU G D A FI /INSPECTION_.' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> is FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE s-7 <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTIONY PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE= INSPECTION BY DATE -,� <br /> • <br /> r , r <br /> f �; E H 1426 Rev. 1-74 I-74 2M <br />