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en4 uJc-s SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FL?hr0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?L%_ <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 to construct <br /> ' and/or install the work herein described. This Application is made in compliance with San Joaquini <br /> 'bounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 17Q�t � T�ry CSan) <br /> JOB ADDRESS/LOCATION R,,�-w� a a r ti ers wct�- 64 11-7 1 ENSUS TRACT <br /> Owner's Name !3 '[9�^ Phone 13!- o,2- � <br /> t .. <br /> Address gy-4 City o- <br /> Contractor's Name / --- License # elig? 'phone -76 7, <br /> TYPE OF WORK (Check): NEW WELL/=7 DEEPEN -/_7 RECONDITION I-7 DESTRUCTION I7 <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 /> T Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> L. Irrigation Gravel Pack Depth of Grout Seal <br /> ! Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,G <br /> Type of Pump V H.P. <br /> r <br /> PUMP REPLACEMENT: %/ State Work Done <br /> /� State Work Done - / L� � -�. �,r _ 1✓�f�� <br /> PUMPREPAIR: 7 _-- <br /> f � <br /> � ,PESIRUCTION OF WELL: Well Diameter Approximate Depth <br /> Z Describe Material 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 /> information is true to the-best my knowledge s d belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL IN R <br /> SIGNED . _ - I TTLE <br /> W LOT PLAN ON RE SE SID'F_,T � <br /> FORDEMTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A /7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E FI NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />