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SPN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 16O1 Hazelton Ave. , Stockton, Cal.,. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2L '7 <br /> f <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. 18762 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J IPSO g Lp/ nr� %IPE CENSUS TRACT <br /> Owner's Name vt1Z KI SGAyl. 7Z Phone */70:514P <br /> Address cSgm� City Z),qc-pg2'6 <br /> Contractor's Name T_( „ g�nl License #I ?nd 4 Phone ,,22O1 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /_7 RECONDITION /—T DESTRUCTION /—T <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /- <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 - W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing CN <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Vr <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /:� �/ ",dy dOA./ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done e <br /> PUMP .REPAIR: / / State Work Done <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO G (d TING ANDrA F AL INSPECTION. <br /> SIGNED E TITLE <br /> '"(DW PLOT PLAN ON REVERSE SIDE Ps"' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q� <br /> APPLICATION ACCEPTED BY DATE U <br /> ADDITIONAL COMMENTS: 17 <br /> PHASE II GROUT INS CTION PRMAIIaINAL INSPECT;ON <br /> INSPECTION BY DATE INSPECTION By//Z,,&, ", DATE <br /> E H 1426 Rev. 1-74 376 2M <br />