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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fO—R,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pkrpit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %wi <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a peruct <br /> and/or install the work herein described. This application is made in compliJoaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ p_- NeAdi, tirmr Ad, CENSUS TRACT <br /> Owner's Name -C� k f w c.x � g. w „ ..,.. .- _ _ Phone <br /> Address i u-i City FSC,?/0P7 _ <br /> Contractor's Names -JD 1I 4W License 321 _)S;� Phone (Q �71g 3tZ <br /> TYPE OF WORK (Check): NEW WELL IX DEEPEN '/-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK �Tir, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSFIELD (a0 CESSP OL/SEEPAGE PIT OTHER p <br /> PROPERTY LINE R 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 �i• Q� <br /> Domestic/public Driven Gauge of -Casing I&n 10It.ctI,R_ <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ' Disposal Other Other Information __S l h <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> t ctor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j/7 State Work Done <br /> PUMP ,.REPAIR: L7 State,Work Doi ii.- ' <br /> ES• RUCTION 0 ? WELL: Well Diam ter • -4 ' proximate Depth <br /> Describe Mat r- j 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 F12MNG AtW A FWAL INSPECTION. <br /> SIGNED TITZE <br /> D LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE It GROU NSPECTION PHAS -IMNAL INSPECTION <br /> INSPECTION $ ATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />