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t' SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE 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 1 YEAR FROM DATE ISSUED Date Issued ZZ 2 <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 gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ . O' CeCENSUS TRACT <br /> Owner's Name ! J� A L 7 ItO Phone — () <br /> Address ��-G City 521 &7&;g <br /> Contractor's Name �� License '��a�L Phoned <br /> �� <br /> f <br /> r <br /> Xy <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION DESTRUCTION /-7 <br /> PUMP INSTAL IO / / PU29 REPAIR /, / PUi+�P REPLACE NT / <br /> ,� <br /> Other �a -1- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUALIC DOMESTIC WELL Rg� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "l <br /> Industrial Cable Tool Dia, of Well ExcavationI <br /> Domestic/private Drilled Dia. of Well Casing <br /> 'Domestic/public Driven. Gauge 6f Casing <br /> -Irrigation-,,-- Gravel;Pack. Depth -of. Grout Seal p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface .Seal Installed By: <br /> _PUMP INSTALLATION: Contractor+t': ` <br /> Type o Pump_. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / 7 State Work Done <br /> 24;i� 4i <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 the..well in use. The above <br /> information is true to the -best of my.-knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI D A FINAL INSPECTION. <br /> SIGNEDega, TITLE <br /> '" <br /> D W.'PL T PLAN ON REVERSE SIDE) " <br /> FO,& DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEIIT GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE /,2- ?:i75 <br /> 3/?6 <br /> E H 1426 Rev. 1-74 <br />