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SAN JOAQUIN LOCAL HEALTH- DISTRICT i <br /> FOR OFFICE USE: : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> II: Telephone: (209) 466-6781 <br /> w APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-Ig-7J <br /> 2Z�e S C y ,�l 8c-t 7->j ;(Complete In Triplicate) leo---b,6, <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. 1$62 and the Rules and Regulations of the San Joa uin Local Health District. <br /> a.-7w <br />' JOB ADDRESS/LOCATION 0m- f IM,It At e,0�' �o�/a���Q � 'Ae e, 14tENSUS TRACT <br /> IP er <br /> Owner's Name �i � Scvri t.Z n � � C�U- / Phone <br /> Address N cz�[a ✓ City pYJ C. <br /> Contractor's Name I� <br /> License /l '�tione -7� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT IX7 <br /> Other I I N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A t L Industrial.. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 B. <br /> PUMP INSTALLATION: Contractor rte <br /> .,Type of Pump H.P. <br /> PUMP REPLACEMENT: '' / State Work Done 9tr w 6 a e- 6/40 <br /> PUMP .REPAIR: '% / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,I <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 �rihe best of my ' ' wl e belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A� FINAL INSPECTIO <br /> SIGNED TITLE �^ <br /> ,h. W Pt-PIAN ON RSE SIDE <br /> it FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYI DATE /�-!�T -,7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY Q. DATE . INSPECTION'BY _ - DATE S- -, 7 - <br /> E H 1426 Rev. 1-7I4 376 2M <br />