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SAN JOAQUIN LOCAL HEALTH DISTRICT , J <br /> -705FOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z�' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sad 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. I86Z and the Rules a4"Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (/ e �� - CENSUS TRACT <br /> y <br /> r G1 <br /> Owner's Name ^G7�1Gj / C` C. -� Phone <br /> Address � �-�; ' City <br /> Contractor's Name � 1 � � 1� License •Zatw`75;7 hone — 7 <br /> IL <br /> TYPE OF WORK (Check) : 1 EW^WELL / DEEPEN µ~RECONDITION /�/� DESTRUCTION /� ` <br /> _- - . __ <br /> PUMP INSTALLATION PUMP REPAIR-/ I PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /3cI OTHER <br /> PROPERTY LINE/a PRIVATE DOMESTIC WELL -Z- PUBLIC DOMESTIC WELL \� <br /> INTENDED USE TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C> �1 <br /> _ x Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public C - Driven Gauge of Casing <br /> Irrigation "gavel Pack Depth of Grout Seal (> <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal ° Other Other Information i <br /> Geophysical Surface Seal Installed By:; B <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump 2 H.P. / <br />` PUMP REPLACEMENT: J / State Work Done <br /> PUMP .REPAIR: J / State Work Done -.- - <br /> DES-TRUCTION OF ;WELL: Well Diameter �_ Approximate Depth <br /> Describe Material and Procedure <br /> I'hereby agree to comply with�all laws arid-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-newr.�rel1, •I will furnish the S n Joaquin ,Loc'.al Health District a <br /> WELL DRILLERS REPORTof well and .notify them before putting the well in use. The above <br /> information is trueto of mynowledge and belief. I WILL ,CALL-FOR A€ GROUT INSPECTION <br /> PRIOR TO GR FINAL I S E N. •, J's <br /> SIGNED TITLE <br /> f DRAW <br /> PLOT PL RE FRSE SI <br /> �ZEI�r � A>` # FOR D ARTMENT USE ONLY <br /> PHASE I fOARSL.1- } <br /> APPLICATION ACCEPTED DATE C734- 7G <br /> ADDITIbNAL COMMENTS: NC,F D,9. Z AjojX- A4L0U1 $4E � <br /> y PHA II G UT INSPECTION Nps TNEsF— r0A1PM6 PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE Q Z t INSPECTION By DATE r <br /> E H 1426 Rev. 1-74 3/7 <br />