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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 11 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 9ONSTRUCTION OR PUMP PERMIT Permit No. <br /> O . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,71 �7�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 <br /> �/Jof �the San Joaquin Local Health District. <br /> /r <br /> JOB ADDRESS/LOCATION ZW. ��d S' '1' 1`t 11 CENSUS TRACT <br /> Owner's Name lie le z N oe �� / Ile- Phone 13 z1 Z2 <br /> Address q x 0-6: f�/+ ? L"t City <br /> Contractor's Name S License # Phone � / <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /� DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 715 <br /> SEWAGE DISPOSAL FIELD ssl�t- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Z& PUBLIC DOMESTIC WELL �. <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool Dia. of Well Excavation AQ <br /> _y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 064f <br /> Irrigation may_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor Z jW QS <br /> Type of Pump ,°fP H.P. <br /> PUMP REPLACEMENT: State Work Done �,P <br /> PUMP .REPAIR: / / State Work Done dv j t' L1,o1, r <br /> DESTRUCTION OF WELL: Well Diameter �7 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 theb of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO .GROU G AND I NSPECTION. <br /> SIGNED TITLE <br /> W..PffT PLAN ON RE LASE SIDE <br /> �. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE jj GROUT INSPECTION P SEI /FIN -INSPECTION <br /> INSPECTION BY DATE Z," -1 $ INSPECTION BY DATE 3- _l $ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />