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'- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EQE OFFICE USE- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ,,,9-&,,y <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 <br /> San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .3 ��I� Gtr /J vrG r� �-ri pr CENSUS TRACT <br /> Owner's Name d2 d e Phone �~-U�D� <br /> Address -71L Z9 GU � ` (� ,-r , �j City .__._ <br /> Contractor-'s Name Cd-Vacs We-LL lDnil.Gcng License # 336709 Phone 634--9568 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/X-/ DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES--50- PIT PRIVY ' <br /> Minim= SEWAGE DISPOSAL FIELD 100 CESSPOOL/SEEPAGE PIT � OTHER <br /> b �tCeA PROPERTY LINE - PRIVATE DOMESTIC WELL 10 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE ATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driv_en..-r. Gauge_ofCas.ing . , ._ - -- . <br /> Irri ation - C.._ <br /> g �-~Gravel Pack Depth of Grout Seal _ $pry I - _ 4 <br /> Cathodic Protection — Rotary Type of Grout remen; <br /> Disposal Other Other Information '4 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 <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 />?RIOR TO GRO I G AN A -ZINAI <br /> j,iINSPF,CTION. <br /> SIGNED TITLE PaA;�ne,% <br /> (DRAW PLOT..PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��- .- _---- _ _ __---- -_ <br /> APPLICATION ACCEPTED BY DAT 9 � <br /> ADDITIONAL COMMENTS: <br /> PHASE'II GROUT INSPECTION _ PHASE, III/FINAL INSPECTION <br /> INSPECTION BY '-'-`DATE"'-p �� INSPECTION BY DATv? -) <br /> E H 1426 Rev. 1-74 1177 . 2M <br />