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s• _ <br /> $ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telep�hone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZf p_yjp <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 No. 1862 a d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ed2 e F /k v CENSUS TRACT <br /> Owner's Name ®" Q Phone 3 O <br /> Address 75'� Vie ,. 0eI.-&zzS Ir��� !-ron�d City <br /> U License # Phone 6 <br /> Contractorf s .Name �t! �'�/�Id <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN/ / RECONDITION /�/ DESTRUCTION /7 <br />#' PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES FIT PRIVY W <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 /> f Industrial Cable Tool' <br /> .Dia. sof. Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal ? <br /> Cathodic Protection Rotary Type of Grout " <br /> a Disposal f4 fi <br /> Other Other Information . <br /> Geophysical ' Surface Seal Installed By: <br /> { <br /> PUMP INSTALLATION: Contractor 111A1 j w e R S'/9 L zlA&g_ Y S2,,9/9/c, <br /> Type of Pump t, ,.. H.P. <br /> PUMP REPLACEMENT:_' ' / / ' State Work_Done 4 <br /> PUMP .REPAIR: / / State Work Done <br /> r f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I Yiereby 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 /> Wafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i= 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW P- T PLAN 'ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 1 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ~ <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> 3�7b 2M <br /> E H 1426 Rev. 1-74 ;,. <br />