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Gf SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> OE <br /> l FOF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zpg_a_ 7� <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, 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ � a7 ✓�� C� �j-1CENSUS TRACT <br /> Owner's Name _ .C: � ��'�� 1 �/? t ��p °�fA�ayaa��, ���� Phone <br /> G <br /> Address ( d Cit <br /> Contractor's Name License 2- Phone v.i!� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %�/_ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION,/ / PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other I 1 — . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal v . <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• <br /> State Work Done T_r��n�_-_r1�•-__-_ lrc /�_ "1 <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 anew 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�Y_2 <br /> owled a an elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL INSPEN <br /> SIGNED TITLE I <br /> D W �'L AN ON VL�tSE SIDE} �r t`i'• <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ ff DATE <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE III/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -ZA <br /> E H 1426 Rev. '1-74 3/76 2I <br />