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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO4 FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_6—_Z *0 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7y, <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 / OF // CENSUS TRACT <br /> Owner's Name r t 1 e, ' 0 <br /> Phone <br /> Address �{ <br /> � A01 city <br /> Contractor's Name k1pzgnv,,u t <br /> 40-9 License # ,!ZrJ Phone 16ty�Ajf <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMp REPLACEMENT / <br /> Other j/7 <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> K Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Gl <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 <br /> PUMP REPLACEMENT: L77 State Work Done <br /> PUMP `•REPAIR% L7 State Work Done <br /> ES-TRUCTION 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 notify them before puttingthe well in-use.. The above <br /> information is true to the-best of myknow dge and--belief. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR G AND FINAL NSP IO <br /> SIGNED I <br /> ITLE ��,./' <br /> LOT P ON ERSE SIDE ' <br /> PHASE I FOR DEPARTME USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I 'I SIN INSPECTION <br /> INSPECTION BY „ DATE INSPECTION BYA 4,,DATE <br />� E H 1426 Rev. 1-74 <br /> 1-74 2M , <br />