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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. 1aL__LA&1_?.) <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 a2g _/_ZX CENSUS TRACT <br /> Owner's Name 4a cu <br /> rla Phone <br /> Address �_51-m City �C <br /> Contractor's Name A`cycLc_-AL /?J" nLicense ��.. Phone 2���7' <br /> r J <br /> TYPE OF WORK (Check) : NEW WELLIX DEEPEN%/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION /� PUMP REPAIR ''/ / PUMP REPLACEMENT /7 <br /> ,Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE P PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> -;P, Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 17- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout 'Seal <br /> Cathodic Protection Rotary Type of Grout �,�. �eta.• <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: Ale <br /> PUMP INSTALLATION: Contractor 10 1 � <br /> Type of Pump H.P. w.... <br /> PUMP REPLACEMENT / / State Work Done <br /> ' r <br /> PUMP .REPAIR: /7 State Work Done <br /> - f <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulateons 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 Sari 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 GROU2WAND PE CT ION. <br /> SIGNED _ rTITLE <br /> DRAW' PL T PLAN 'ON REVERSE SIDE) <br /> FOR DEPAR W NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9'/-20/7 $ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E III/FINAL INSPECTION <br /> INSPECTION BY DATE b INSPECTION BY DATE 7 y1T <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M'p <br />