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L _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> L THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuad / 77 <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 Joaqui <br /> LCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 �r1/r1- fit,yrs CENSUS TRACT <br /> Owner's Name 3Q h 57-nc lC toe Phone <br /> L i SIG�/— 3f��_ <br /> Address lcgF 61,// t Tt' n _ City et< W <br /> Contractor's Name A`61 /Zs S Y JAjell ApinZle License $a�V,09r Phone 7yS 3�'•7 j <br /> L <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> LOther <br /> DISTANCE TO NEAREST: SEPTIC TANK -�;!� SEWER LINES 077' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD IeV CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE§ PRIVATE DOMESTIC WELL AdM2-f PUBLIC DOMESTIC WELL <br /> L INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _�Cable Tool Dia. of Well Excavation /-Z— <br /> _ Domestic/private Drilled Dia. of Well Casing �lfT f <br /> —L Domestic/public Driven Gauge of Casing /Of <br /> L Irrigation Gravel Pack Depth of Grout Seal 5-1) <br /> q <br /> _ Cathodic Protection Rotary Type of GroutJ�- <br /> -Disposal Other Other Information v <br /> _Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump H.P. r` <br /> PUMP REPLACEMENT: / / State Work Done <br /> L. — <br /> — <br /> PUMP .REPAIR: / / State Work Done <br /> L 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTIN AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSES E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> L APPLICATION ACCEPTED BY T-LA DATE <br /> ADDITIONAL COMMENTS: <br /> P44sn Yl AOUT INSPECTIE PHAEILIA/YINAL INSPECTION f <br /> INSPECTION BY DATE # INSPECTION DATE 7 JS <br /> I` E H 1426 Rev.' -74 6777 - 2M T <br /> L <br /> L <br /> L <br /> L <br />