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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />,E_ FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> .. Telephone: (209) 466-67,81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No Z?-,64;L ie,) <br /> THIS .RERNIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is reby 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 Jpaquin <br />` County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br />,,Owner's Name e�sde+C.�_ 11 a'R'. Phone <br /> Address ,�a e & _ City <br /> Contractor's Name License # Phone <br />` TYPE OF WORK (Check) : NEW WELD DEEPEN /_/.,. -RECONDITION /7 DESTRUCTION, /"7- <br /> W <br /> PUMP INSTALLATION / j; 'UMP REPAIR / / PUMP REPLACEMENT' : <br /> /-- <br /> - O her <br /> FIDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> E, <br /> SEWAGE DISPOS FIELD CESSPO(YL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE ('.WELL CONSTRUCTION SPECIFICATIONS `` <br /> Industrial K � ble Tool' Dia. .of Well Excavation 12 <br /> )L_ Domestic/private Drilled Dia. -of Well Casing zo <br />' Domestic/public Driven Gauge` of Casing <br /> Irrigation -Gravel: Pack . ' ,Depth of Grout Seal <br /> Cathodic -Protection Rotary Type oft-Groir't C M <br /> Dis osal Other' - "P � - : Other information <br /> _Geophysical - Surface Seal Installed B <br /> PUMP INSTALLATION. <br /> Contractor <br /> Type of Pump .. H.P. . <br /> PUMP REPLACEMENT: / / ate Work Done <br /> If <br /> PUMP .REPAIR: / J st'*-te Work Done <br /> ES-TRUCTION OF WELL: Well Diameter iameter Approximate Depth <br /> Describe Material and: ocedure <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 FIFTZIN DAYS <br />` <br />,nft�er completion of my work on a new well,, I,will furnish the San Joaquin Local Health District a <br />'*ELL DRILLERS REPORT .of the well and notify ,them before putting the -well in use. The above <br />:Information is true -to the best of my_knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUT NG Atj A fINAL INSPECTION. <br />"SIGNED - TITLE <br /> DRAW PLOT 'PLAN ON REVERSE SIDE - <br /> M. <br /> FOR DEPARTMENT USE,ONLY' <br />'PHASE I - <br /> APPI.ICATIONi ..ACCEP.TED BX DATE <br /> SAD TIONAL C0*fWT-s_:, <br /> P I ' GROUT INSPECTION r PHA II.-FINAL INSPECTION <br />'INSPECTION B ,:DATE WPAION BY DATE oO-Z 7-22 <br /> E H 1426 Rev. 1-74 <br /> 1f.z7 . <br />