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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 2Y-422 <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued(Complete In Triplicate) <br /> Application is hereby made t the San Joaquin Local Health District for a permit to construct f <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/LOCATION L,L C�1 } S_� CENSUS TRACT <br /> Owner's Name 91/� l T°l4 OA--� _ Phone b r__�-e <br /> Address / / / ( 2_ L 2- City <br /> G �01 Z16 <br /> Contractor's Name' Z`T}� License l Pho <br />'Y TYPE OF WORK (Check): NEW WELL , DEEPEN '17 RECONDITION � DESTRUCTION <br /> PUMP JNSTALLATION / / PUMP REPAIR ,/-7—pump REPLACEMENT J? <br /> Other / / \, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> a . Domestic/private `` i Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �! <br /> Cathodic Protection I i/ Rotary Type of Grout <br /> Disposal I Other Other Information ." <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type-of Pump 'H.P. <br /> PUMP REPLACEMENT J / State Work Done <br /> _PUMP=-REPAIR: - ./«/ �-State .Work Done ,;-�•--.-;t . <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate pth / + <br /> Des cr feria and Procedurka ,jam T— <br /> I hereby agree to comply with all laws and regiilations of the Sati Joaquin Local Health District <br /> k And the State .of California pertaining to or regulating we11''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 GROUTING AND A F'INAL� INSPECTION. <br /> H SIGNED j TITLE <br /> } DRAW PLOT PLAN ON REVERSE SIDE -- - `�— <br /> FOR ))EPARTMENT.USE ONLY <br />' :PHASE I <br /> APPLICATION' ACCEPTED BY DATE 3 2 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION ifs. PHASE II FINAL INSPECTION <br /> INSPECTION BY .DATE INSPECTION BY i DATE !!g_j3_'2�----= <br /> i , <br /> 8Z 1426 Rev. 1. 74 L/75 2M <br />