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L-o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFF CE USE: 1� E. Hazelton Ave. , Stockton, Cf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2.2__,1a, <br /> �. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'-13_-27 <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 Joaquii <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /e? V1 7 c -2 CENSUS CENSUS TRACT <br /> Owner's Name 14&_k �Af,y ,e � Phone <br /> Address .9E ALI t_S_f— City ,s'klc,y- , <br /> Contractor's Name l ko License $ /f372.rPhone <br /> TYPE OF WORK (Check) : NEW WELL / /ALDEEPEN /—/ RECONDITION / _ <br /> _/ DESTRUCTION / <br /> PUMP INSTALLATION /—/ PUMP REPAIR 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 /> Industrial Cable Tool Dia, of Well Excavation <br /> _�A Domestic/private Drilled Dia. of Well Casing _ 4 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor \ , <br /> Type of Pump H. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done ���.�.� ,/IA7&r c% [j� ;f>,pa _\x� <br /> DESTRUCTION 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. kn =eelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GjjQUTTNG AND A FINAL INSPE ON. <br /> SIGNED y TLE Q 1 <br /> ( RAW LOT PLAN ON REIMRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I !� <br /> APPLICATION ACCEPTED BY J , r ,;!f DATE 9 3 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �4,g . DATE -/,,'-?? <br /> E H 1426 Rev. - I-74 <br /> 6/77 . 214 <br />