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SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> FOF OFF&C-B USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -r7-PO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ILLLII <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 /> JOB ADDRESS/LOCATION '3��- L kA,P CENSUS TRACT <br /> Owner's Name 140 e,V\ ®� A4, e VrPhone _ <br /> t, /� i <br /> L <br /> Address `3 1y\ 1� .%73 ., kA _VA City <br /> Contractor's Name ?jam�fj� per.=i%'�' License # Phone <br /> .& <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTAL TI N PUMP REPLACEMENT <br /> Other / / 4A _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1a_0— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT t1� OTHER <br /> PROPERTY LINE'fD PRIVATE DOMESTIC WELL PUBLIC —MEMESSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 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 By: <br /> PUMP INSTALLATION: Contractor d1Qin& k <br /> Type of Pump + H.P. <br /> PUMP REPLACEMENT: / / State Work Done � � 14 <br /> n <br /> PUMP .REPAIR: / / State Work Done <br /> C <br /> DESTRUCTION OF WELL: Well Diameter Approxi e Depth RJ 'Q <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 be t of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AN FIN INSP ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION P _1 '/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ` DATE _ -J 7 <br /> 2M <br /> E H 1426 Rev. 11-74\ <br />