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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> �j <br /> FOR OFFICE USE: Y/""'1601 E. Hazelton Ave. , Stockton, Calif. ` } <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.)2Z^ t iyo <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 Joaquin <br /> County Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> I <br /> JOB ADDRESS/LOCATION 25862 So. Curtis CENSUS TRACT , <br /> Owner's Name Ray �idervaart Phone 599-7582 <br /> i <br /> same <br /> Address _ City <br /> ' - - Contractor's Ekense <br /> Contractor's Name �• ja A , �' License �� �o,���,��4Phone 529-202© <br /> i' <br /> TYPE.OFWORK (Check)_: NEW,WELL_/ / _pEEPEN /_/, ;RECONDITION_ /-_/__,DESTRUCTION_ <br /> _ <br /> _ .PUMP .INSTALLATION,:/ / PUMP REPAIR / / PUMP`REPLACEMENT` <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE OD M STIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information- i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: /x/ State'Work Done Pul I old jetireplace w/3/4hp subm <br /> - <br /> PUMP .REPAIR: / / State Work Done" ' <br /> DESTRUCTION OF WELL:- Well Diameter Approximate Depth <br /> Describe Material and Procedure 5 <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 thewellin use. The above <br /> information is true to the best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRRU3,jEqJANR A FINAL INSPECTION. .N <br /> SIGNED TITLE <br /> „ DRAW PL T" PLAN ON REVERSE SIDE „.� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION P E I,I2SAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. '1-74 <br /> { 3/76: k <br />