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4 " g SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fro&.OFFICE USE: 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209.) 466-6781 " <br /> APPLCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22=.1J_W <br /> / 77- 7P <br /> THIS PERMIT (EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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 JAG 0'$!/ CENSUS TRACT <br /> Owner's Name 2)1Phone ' <br /> AddressCit <br /> � � J y '.� <br /> Contractor's Name 0 1/A44 d J4 S [.C/ -s License hone <br /> TYPE OF WORK (Check.): NEW WELL/9 DEEP EN -/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION g—PUNP REPAIR /� PUMP REPLACEMENT 17Other <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD �""�' CESSPOOL/SEEPAGE PIT/��f-{?THEA <br /> PROPERTY LINR�PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 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 ""7`}� Driven Gauge of Casing <br /> irrigation Gravel Pack- Depth of-,Grout Seal 4- <br /> Cathodic <br /> -Cathodic Protection Rotary Type of -.Grout <br /> Disposal Other Other Information <br /> Geophysical , _ �Surface Seal Installed B ' <br /> r <br /> PUMP INSTALLATION: Contractor 's ,S <br /> Type of Pump <br /> PUMP REPLACEMENT: . /-7 State Work Done <br /> - 77 <br /> PUMP .REPAIR: /�/ State Work Done <br /> .DES-TRUCTION 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 'const•ruction.. Within FIFTEEN DAYS <br /> .after completion' of my work on a new well, I will furnish the San Joaquiu 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEGT <br /> SIGNED �A-.�LE &/=� <br /> PL ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 'PHASE II INSPECTIONY, <br /> INSPECTION BY , DAVE A INSPECTION BY /1 DATE A •�' �� � <br /> E H 1426 <br />