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'✓� C-,�a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE. OFTICE 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 O 7 <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 San Joaquin Local Health District. <br /> .5 8 SS' E ' `.,.i c q C-+�+�C� �- ?10�- n5ti7-o ff <br /> JOB ADDRESS/LOCATIONr e70 A/ CENSUS TRACT <br /> Owner's Name , Q Phone <br /> (� a <br /> Address s C12C�iCity <br /> Contractor's Name License #/Zg-7zS""15hone a.• -7 76 <br /> i� <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 SEWER LINES PIT PRIVY �^ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing r <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - f- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Dane 4P "Pe, <br /> V r ' <br /> DES<TRUCTION 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 knowle d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL i SP TIO <br /> SIGNED !TLE ?,n a- c - <br /> W PL AN ON SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE a Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 1 IN CTION PHASE II/FINAL INSPECTI r <br /> INSPECTION BY V Z DAT INSPECTION BY DATE 2 <br /> 17/7. ; 2M <br /> E H 1426 Rev. 1-74 . <br />