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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FORfOFFICE USE: 1601 E. Hazelton Ave.'; Stockton, Calif. <br /> ' Telephone: . (209) :466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q�lvl- <br /> r . . (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: 1862-and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /10C) ] �,. C <br /> � L''7'n �� �`°� CENSU5 TRACT <br /> Owner's Name saw -� / 7 GPhone�.��`,z, 73 <br /> J > <br /> Address rte .,- , res ¢. City 2 CZ A LC N <br /> Contractor's Name�ij r.j b ti QA1 - License #,222pj4)Phone # <br /> TYPE-OF WGRK--(Check)----NEW-*VELI. /_7 DEEPEN /_7 RECONDITION /_' DESTRUCTION _� <br /> ^" PUMP INSTALLATION /, PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other L_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES) PIT- PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SERFAGE PIT OTHER s <br /> DI;D USE <br /> PROPERTYTYPEOF WELL <br /> CONSTRUCTION LINEIVATEDOMESTIC PUBLIC DOMESTIC WELL <br /> _ <br /> INTENDED - N 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 /> IrrigatiorC o Gravel Pack Depthf of Grout Seal <br /> Cathodic Pro.t'ection16 „ `Rotary Tape '-of Grout <br /> Disposal Other Other -Information �^ <br /> Geophysical Surface Seal. Installed BY: <br /> SUMP INSTALLATION: Contractor - _ <br /> Type of Pump s� - "- - - H.P. <br /> 4 of <br /> PUMP REPLACEMENT: State Work Done <br /> tPUMP 'REPAIR: /_7 State Work Done <br /> ,RES;TRUCTION OF WELL: ell.Diameter F Approximate Depth <br /> Describe Materi&14 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 /> 4 information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> EPARTMW USE ONLY <br />' PHASE I ! / <br /> APPLICATION ACCEPTS X04_1_//V0_r/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION !HAS II FINAL INSPECTIO <br /> E <br /> INSPECTION BY DAT -INSPECTION BY DATE Q <br /> y} <br /> 1-74 2M <br /> E~H 1426 Rev. 1-74 , V <br />