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L�6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�jO FICE WE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. <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 Co'"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 /> .TOB ADDRESS/LOCATIONI3SUS TRACT S �� <br /> Owner's Name ^m 2.P�T� _ Phone 8 3 5--46 5'1 <br /> Address 6 Blvd City , 'Tracy <br /> Contractor's Name Heanings Brosillin Co. jInc. License # 290813 Phone 522-1031- <br /> -Rd... <br /> 22-1031- <br /> -W. ble Rd.. Modesto <br /> TYPE OF WORK (Check) : NEW WELL /xX DEEPEN '/? RECONDITION /� DESTRUCTION I=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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 111t <br /> x Domestic/private Drilled Dia. of Well Casing 611 ala st is <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout _Rent.nni to ._ <br /> Disposal Other Other Information - <br /> t Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f-1 State Work Done <br /> PUMP-tREPAIR: <br /> + Approximate De th Qb <br /> ,)ES•TRUCTION OF WELL: Well Diameter L PP <br /> Describe Material and Pro duce Cil <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 /> 1 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 FORA -GROUT INSPECTION <br /> PRIOR TO GROUTING MD FINAL SPECTION. <br /> SIGNED TITLE <br /> (DUV PLQ PLAN ON SE SIDE <br /> FOR EP T USE ONLY <br /> PRASE I ; <br /> APPLICATION ACCEPTED DATE4 7�_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT- N P I NAL IN <br /> INSPECTION BY DATE INSPEC j ` <br /> E H 1426 Rev. 1-74 1-74 2M <br />