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3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. /s-_Ideal, <br /> Telephone: ' (209), 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. /° <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,=3L75 <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. <br /> � JOB ADDRESS�i' J� <br /> �t CENSUS TRACT <br /> i <br /> Owner's Name 56f&LIZ Phone <br /> �• Address <br /> I City <br /> k ' � �--. <br /> Contractor's Name , License Phone �i•�� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN ' RECONDITION /_7 DESTRUCTION /7PUMP INST CA �TION PUMP REPAIR / / PUMP REPLACEMENT / <br /> other ! I <br /> DISTANCE TO NEAREST: SEPTIC TANK t? SEWER LINES .99&- PIT PRIVY <br /> [SEWAGE DISPOSAL FIELD C /SEEPAGE PIT a f-OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 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 e <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 <br /> Geophysical - 'Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor ' , ; 19' <br /> Type of PUMP' >i , ' H.P. <br /> E' <br /> • I t R� ' �,:M y . wrr w ry�r.. .,ws - +.rY1W. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP .REPAIR: /� State Work Done - <br /> E&TrRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 by worts on a new well, I will furnish the .San Joaquin Local Health District : <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- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND' A FINAL INSPECTI L <br /> SIGNED II TLE ! <br /> i; T ON REVERSE SIDE <br /> FWDtPARTMENT WE ONLY <br /> PHASE I A DATE F <br /> APPLICATION ACCEPTED Y . <br /> ADDITIONAL COMMENTS:: <br /> PHASE II GROUT INSPECTION PHASE III/FTAAL INSPECTIQN <br /> INSPECTION BY .II. DATE INSPECTION BY ATE s <br /> tt w <br /> 1-74 2M <br /> .kE g 1426 Rev. -74 <br />