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e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOF, OFF-z'"E SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 ��/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 0­��/- <br /> (Ne 2'f ,hJ' Fft 64+w4-y-9T (Complete In Triplicate) _ t(o3--r2V.._[ <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 /> -296G`Al 4 F E/*14-r A4 i c-E TZ 0 7-.-3*97E Sic, 3-5- <br /> JOB ADDRESS/LOCATION 95V i& of 141Wly 1,lCENSUS TRACT <br /> Owner's Name 977- WdkD Phone <br /> Addresssp/Ilp f�' Cit <br /> Y .5TGc� 7o/�/' <br /> Contractor's Name d License # 371fff Z_-Phone 7 <br /> itl <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP-REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 14�9 SEWER LINES PIT`- <br /> PRIVY-SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-P-17 OTHER <br /> PROPERTY LINa,91?RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �_ , CONSTRUCTION SPECIFICATIONS <br /> Industrial _X Cable Toil"` "Y" Daa:of-Wel '"Excavation �� <br /> --�( Domestic/private Drilled Dia. of Well Casing ICY <br /> Domestic/public Driven Gauge of Casing, /Z <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 B <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 WOUTING, AND A.FTNa INSPECTION. <br /> SIGNED TITLEr _ <br /> (DRAW PLOT 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 PHASE IIT,)/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' 7,[,, <br /> E H 1426 Rev. - I-74 <br />