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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS a24J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZZ/-9-7S <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or insiall the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and <br /> t�e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7�j� J��`�1 D.Q LAI .,V e -� CENSUS TRACT <br /> Owner's Name 14.R,, _ W)11-1A L/ S LHQC,/)21A A1 Phone ,j/w -- `�l� <br /> Address '- �C City J L <br /> Contractor's Name CIA f lr ]A�I'y 4 :} E(� L1 i P, C_6• License # GZ Phone <br /> TYPE OF WORK (Check): NEW WELL Zg DEEPEN '/—/ RECONDITION %j DESTRUCTION 17 <br /> PUMP INSTALLATION /_/ PUMP REPAIR-/-7—pump REPLACEMENT f7 <br /> Other /% _ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <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 el <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal 611) <br /> Cathodic Protection s Rotary Type of Grout QU rOlIl Td- <br /> Disposal <br /> EDisposal Other Other Information <br /> Geophysical Surface Seal Installed By: 6iNV71?1Je 70IZ <br /> PUMP INSTALLATION: Contractor �L �' f1_ .t.r. �-_ �- <br /> Type of Pump .._., _ ..,. /� H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR: / ./ State Work Done <br /> DESTRUCTION 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 San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and nota them re putting. the..well in.use.... .The above <br /> information is tiue to the-best edg a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 T G A PELT _ <br /> SIGNED TITLE WN/ <br /> (D PLOT PLAN VERSE SIDE <br /> if <br /> FOR DEPART T US NLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/,FINAL INSPECT4N. <br /> INSPECTION BY DATE INSPECTION BY „r DATE 7� <br /> E H 1426 Rev. 174 <br />