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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E: Hazelton-Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L- 2_Z_,Ey3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1r���2.7(_-/v_-_.d`_( ai j( D2_ (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 /> .SOB ADDRESS./LOCATION 0C, yzt.?to CENSUS TRACT <br /> Owner's Name L p-� Phone ` f� <br /> Address <br /> City r <br /> Contractor's Name ��� �� y <br /> .Le. License Phone <br /> . 4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /% RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other Liu /`` 93 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERr <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ___,LDamestic/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 r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 2j- <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 F` <br /> r <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 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 INSPECTION. <br /> SIGNED TITLEir e� , <br /> D W <br /> 40t PLAN ON REVERSE SIDE) is <br /> FOR DEPARTMENT USE ONLY h <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE 7 7 t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE I I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY_=1a1,. DATE <br /> E H 1426 Rev. 1-747b 2M <br />