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E <br /> C6�, /gyp ��' SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFIG USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP- PERMIT Permit No. Z&_ F'a yo ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED ' Date Issued �a -7G <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. S <br /> JOB ADDRESS/LOCATION �r� ixs-✓ Ll ,c-�� � c� f- / CENSUS TRACT <br /> Owner's Name ,fc�cc 1' C11„f _ Phone <br /> Address3f CO�r cs �1 -- -- - City <br /> Contractor's Name CAIasi . License # &n-2-�one C `Alf <br /> ' Z4 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /�/ RECONDITION / / DESTRUCTION /_7AL <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <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 j <br /> T Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled 4Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \ <br /> c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary , Type of Grout (ni <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor - ' � � C-4 <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - c44,z-r_ 6 CIA eft x �,-'�` <br /> b®A / . �� 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f - <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 of y no edge`and belief. I WILL CALL FOR A GROUT INSPECTION <br /> G ' <br /> PRIOR TO U ING AND A FINAL INSPE IO <br /> SIGNED <br /> or D W- Pt PLAN 'ON RMRSE SIDE) i. 1 <br /> toe FOR DEPARTMENT USE ONLY I <br /> PHASE I / <br /> APPLICATION ACCEPTED'BY DATE ` <br /> ADDITIONAL 'COMMENTS: <br /> PHASE II GROUT I ECTION f PHASEAlIVFINL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/75 2M a <br /> E H 1426 Rev. .1--74 <br />