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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ii OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> L�i 'Telephone: (209) 466-678 . <br /> If APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 u1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1_14t-_,7S- <br /> (Complete <br /> 14t--7S(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 /> JOE ADDRESS/LOCATION _ �� ��Q -P9 L"Z2 19G Ill/ A ! ---__-. CENSUS TRACT <br /> Owner's Name AIN 11A7, �)I��J _ _ _ Phone q7 7-16—Z i- <br /> Address DQ City/ G11� <br /> Contractor's Name �'i�fj rT� �>ti/��� G�]O s C� . License # 2 Phone <br /> TYPE OF WORK (Check): NEW WELL A7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /-7—PUMP REPAIR /-7-pump REPLACEMENT /-7 <br /> Other / I <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 G <br /> Industrial Cable Tool 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUI� '.REPAIR: /-7 State Work Done - <br /> MITRUCTION OF WELL: Well Diameter Approximate Depth <br /> W' 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 con6truction. 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 TQ TING AN A FINAL INSPECTION. <br /> SIGNSTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEYARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ r <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE.,III/FINAL INSPECTION <br /> INSPECTION BY DATE _ -��- Ste, INSPECTION BY - DATE J <br /> E H 1426 Rev. 1-74 1-74 2M <br />