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SAN JOAQUIN L=A_L j ALTH. DISTRICT <br /> FO „ <br /> E OFFICE USE: 1601 E. N.azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued Lz_4j -2.6 <br /> (Complete In Triplicate) <br /> j Application is hereby made 'to the San Joaquin Local Health District for a permit to construct <br /> k and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinarice'No. 1862 and the,Rules and Regulations of the San Joaquin Local Health District: <br /> `JOB ADDRESS/LOCATION1664,t0. CENSUS TRACT <br /> Owner's Name '{ J A djj Phone C599,-Z//6 <br /> Address City . <br /> Contractor's Name Zwtuiaa 26i&aLicense # 6&Y/3 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> `J <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES ,%¢- PIT PRIVY <br /> a 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 �� C <br /> ^� Domestic/private Drilled Dia. of Well Casing S �' <br /> Domestic/public Driven Gauge of Casing /a 61-7 [� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type�of Grout `o <br /> 4 ^ 'Disposal Other Other Information ' V <br /> f "s . Geophysical 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractors <br /> Type of�Pump i H.P. <br /> PUMP REPLACEMENT: / / State -Work Done <br /> ` PUMP .REPAIR: / / State Work Done _ <br /> --�-- <br /> bES•TRUCTION OF WELL: Well Diameter -- Approximate Depth. <br /> Describe Material:-and--Pr"ocedur-e—i <br /> I 'lereby agree to comply with all laws ,and regulat,ioizs of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> afiter 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.iputting the..wel1. in use. The above <br /> information is true to the-best of my..knowledgeL*and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A F/TVAL INS CTIO . <br /> SIGNED A11141 01iTLE11 <br /> (DRAW .T,. PLAN ON REE E SIDE) <br /> { R DEPARTMENT USE ONLY <br /> IH <br /> PASE I ; �. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _" ` .. - <br /> _ = P E GROUT -INSPECTIO ^'+- _ P EII=/ "NAL-4INSPECTION_ <br /> INSPECTION BY DATES INSPECTION BY f DATE <br /> E H 1426 Rev. 1-74 ..x� � �� <br />