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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,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 ;7-31- <br /> (Complete <br /> -3/-(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit. to construct <br /> and/or install thework 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/LOCATION ,� . �G ©e q e 0 t�Nn 1, Ce►., CENSUS TRACT <br /> Owner's Name A EGG S - Phone 6 ^6 <br /> Address 2V MAIM S- City 70Ck7-QA/ <br /> Contractor's Name N AC&--Aa License #3 <br /> 0�2/3 Phone <br /> A <br /> TYPE OF WORK (Check) : NEW WELL ./ DEEPEN. /:7 _.RECONDITION FT—DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT J.7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES Q�� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SS POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATEs- OQ STIC_ WELL PUBLIC DOMESTIC WELL M <br /> INTENDED USE TYPE OF WELL ""` "' CONSTRUCTION SPECIFICATIONS "- <br /> Industrial Cable Tool Dia. _of"Weil Excavation p" <br /> Domestic/pr.ivat,e,l Drilled- rt' r: Ca, Dia of `Well Casing <br /> Domestic/public' Driven Gauge of Casing O,. V G, <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> ' .Cathodic Protection Rotary -- ' <br /> � Type of Grout /�FjY/2�jT-E <br /> Disposal Other Other Information ; — <br /> Geophysical Surface Seal Installed B p <br /> k ` <br /> PUMP INSTALLATION: r Contractor <br /> 7Type of Pump H.P. <br /> 1 . <br /> PUMP REPLACEMENT: / / State Work Done- <br /> PUMP -REPAIR: <br /> one.PUMP REPAIR: / / State Work Done <br /> r <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 bez7t- of- my�'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> i PRIOR TO GROU G AND A F INSPEC N. <br /> SIGNED - TITLE <br />{ __(DRAW PLOT. PLAN-ON REVERSE SIDE). <br /> r PHASE T i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ­ZZ' DATE 3 <br /> ADDITIONAL COMMENTS: ( Z;4;;;l <br /> PHA I ROUT INSPECTION iPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ,. INSPECTION BY DATE j -�8 <br /> E H 1426 t Rev. 1-74 1/77. _. i <br />