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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br />{; <br /> "FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 7J <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. l <br /> "JOB ADDRESS/LOCATION A16 3 c2 { <br /> . i CENSUS TRACT <br />`10wner's NameViaPhone <br />`~"Address Ms s e k. O,)_ Cit '')44 J <br />`Contractor's Name s �� License-# 9biophone 93 1��0 i <br />;,TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION /� PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other /7—/ + <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 'j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing VNiV1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 4otar <br /> ravel. Pack Depth of Grout Seal t. <br /> Cathodic Proe <br /> ,� .ction yType of Grout <br /> Disposal 4ther Other Information <br /> Geophysical Surface Seal Installed By: �- <br />;;PUMP INSTALLATION: Contractor� oIj= ® , <br /> r.: Type of Pump - - � _,_ „ --•---- H.P. <br />'-k� UMP REPLACEMENT: / / State .'Work Done <br />`>p.EJMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF•WELL.: Well Diameter a -j^ ' -I Approximate Depth a <br /> Describe Material and Procedure <br /> r _ <br /> pI' hereby agree to comply with all laws and regulations of the San 'Joaquin Local Health District <br /> j.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 <br /> DRILLERS REPORT of -the well and notify itgem'•before, putting`�the`vell in use. The above <br />`information is true to the best of my. knowledge and,,belie£c: r I <WILL.CALL R A GROUT INSPECTION <br /> PRIOR TOG UTING 4D FINAL INSPECTION:. <br /> SIGNED ~ " *° `' TITLE 1' # <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> `PHASE I #{ <br />:APPLICATION ACCEPTED BY DATE 7 7 <br />'ADDITIONAL COMMENTS: <br /> PHASE II 'G UT',INSPECTION PHASA IT FANA14fINSPECT ON , <br /> £XNSPECTION BY, ,_ r DATE INSPECTION BY DATE 2 <br /> ;' E H 1426 Rev. 1-74 <br />