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g J / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx.OF_FI CE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,g�- r.2 2p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-.30-26 <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. 3$62 and y $ Rules and Re <br /> �gationa of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONdL <br /> ,(ry C' / CTSUS TRACT <br /> Owner's Name c� Phone -' <br /> Address ` Cityr��= n� <br /> Contractor's Name 00 L 6d1t. r✓ License #C222EWPhone Za <br /> TYPE OF WORK-(Check) : NEW WELL/7 DEEPEN/7 RECONDITION fj <br /> _ J DESTRUCTION f <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-DOMESTIG-WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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.P. <br /> PUMP REPLACEMENT: / State Work Done Z� j-z <br /> PUMP .REPAIR:T /% 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 FOa A GROUT INSPECTION <br /> PRIOR TO GROUTM AND A FM JApECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION E II NAL NSPECTI <br /> INSPECTION BY DATE INSPECTION AIY7 DATE <br /> E H 1426 Rev. 1-74 /' - 4/75 <br />