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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �E-,­27�Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z 7 <br /> (Complete In Triplicate) b !3- It Lf <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .�/f �o - -G, 4"P. CENSUS TRACT <br /> Owner's Name r Phone 6 L k <br /> Address ,� �. -O. 7 �L.r-�-v City <br /> -a- <br /> Contractor's Name T (� License 110 P-3 7 3Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / I RECONDITION I I . DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR jF PUMP REPLACEMENT /_7 <br /> Other <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 /> Ind-ustrial.-- ----~_ --- - -Cable -Tool`` D14'. -of -We11 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 Qt <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump -- - — H.P. <br /> PUMP REPLACEMENT: i <br /> State Work Dane t <br /> � yl <br /> PUMP REPAIR: State Work Done �� pc_•�-vhf r r` _ __ = <br /> DESTRUCTION OF WELL: Well Diameter T- 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 putting the well in use.. The above <br /> information is true to the best of my kn ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AN A FIN TNSPECTI <br /> ,SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2-' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE T ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J <br /> 2M <br /> E H 1426 Rev. . ]-74 <br /> n�%7 _ <br />