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Q'o V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE7OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2, .,2. ,l p <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 V f.(/, 4VEEgjn1&CENSUS TRACT <br /> Owner's Name s ine 30-1 / S� .,� <br /> or <br /> Address �� S _ LGA cityQ <br /> Contractor's Name Z License #& 2.? Phone 3C L-ILY� <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN -/-7 RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR. PUMP REPLACEMENT f J <br /> Other /-7 <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 /> Industrial Cable Tool Dia, of Well Excavation (A <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _, 1 <br /> . Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Outer Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State Work Done <br /> iDESTRUCTION OF WELL: Well Diameter 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-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG D A AL INSPECTION, <br /> SIGNED TITLE <br /> DRAWPLOT PL <br /> PHASE I AN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED &5j51V DATE --I'L f� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRAS TTI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f_VAZ4- DATE -0--L-24- <br /> E H 1426 Rev. 1-74 1t/75 2M <br />