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SAN JOAQUINL-OCA tEALTH DISTRICT <br /> FOK*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,4&dgj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued 90-76 <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 aid ulatione of the San -Joaquin Local Health District. <br /> 3 5-9 � f� <br /> JOE ADDRESS/LOCATION ! T a ` JA CENSUS TRACT <br /> Owner's Name QLAO Phone <br /> Address City rrQ ag -- <br /> Contractor's Name License UPhone f-:3g= M:tO <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN •/-7- RECONDITION /_7 DESTRUCTION TT <br /> PUMP INST�TION / / PUMP REPAIR/7-pump REPLACEMENT /7 <br /> Other /7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK D!µ 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 /> ---- .w Domestic/private Drilled Dia. of Well Casing /jr e_oh <br /> Domestic/public Driven Gauge of Casing amu. 14" <br /> Irrigation Gravel, Pack Depth of Grout Seal U 4- <br /> Cathodic Pr_otect__ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical --Surf aceL Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work <br /> PUMPIREPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 6 p ox mate Depth p 0� <br /> - Describe Material and rocedure <br /> I hereby agree to comply wi h a1 la s and re lations o e San Joaq in Local Health District <br /> and the State of California pertaining to or r gulating el '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 TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> i' 't" .i .1:•' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _�,� � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASIRIIZI FJHAb INSPECTIOIJ <br /> INSPECTION BY :J�;64- DATE Z. 2,Z INSPECTION BY DATE 01 <br /> Y <br /> E H 1426 Rev. 1-74 - <br /> x,/75 2M <br />