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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,2 .O- (� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 �7 <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. i <br /> JOB ADDRESS/LOCATION _ �� e �.( CENSUS TRACT { <br /> Owner's Name �JG� �/'�ylf --_ -- Phone <br /> Address cityi <br /> Contractor's Name �f License rz Phone JAZZ <br /> i <br /> TYPE OF WORK -(Cheek) : NEW WELLyx 'DEEPEN / / ; RECONDITION / / DESTRUCTION f� <br /> i <br /> . - — dTMP IN-STALLETION bCI� PU1T_REPAIR / /T"PUi�P�tEPLACEMENT�'"/ y <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS�FIELD CESSPOOL/SEEPAGE PIT OTHER A <br /> PROPERTY LINE RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation zep �� <br /> X 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 <br /> Rotary Type of Grout l' � <br /> Disposal T Other Otlier Information 'a' <br /> Geophysical Surface Seal Installed B e, <br /> PUMP INSTALLATION: Contractor ,l r _ { <br /> Type of Pump H.P r -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> — f <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter AN-90 (« Approximate Depth _Zar�) ^ <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 i <br /> WELL DRILLERS REPORT he well and notify them before putting the well in use. The above <br /> information is t to t. a best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND SP ION./ <br /> SIGNED TITLE IZZ:1::;7'�e iI <br /> ()RAW PL T <br /> PLANON REVERSE SIDE) ' ; { <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU INSPECTION PHAS I/FIML INSPECTI N <br /> FN'S-PECTION BY 7_25-_r2) DATE .._ INSPECTION DATE <br /> 3/76..... 2M <br /> -E H 1426 Rev. 1-74 <br />