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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk.'OFFICE 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 <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 //,T- <br /> j 5, AV,37'//V Rb, _ A1VTEG,4 CENSUS TRACT <br /> Owner's Name ESTE_ - Phone -'?92-- !2Y06 <br /> Address /679 S. Qyg2r_-� A& City ,_&4A1T',_6Cj6 <br /> Contractor's Name Alllnz4 License Qr,��Phone <br /> TYPE OF WORK (Check) : NEW WELL XT DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE20-OPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tN <br /> Industrial Cable Tool Dia. of Well Excavation /Q f, <br /> _ Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing 1,7, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _6�N7- A/®-r-E <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: AlOdgz 'C <br /> PUMP INSTALLATION: Contractor AIVACK AIIA?v4 <br /> Type of Pump iQ_SH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , Approximate Depth 1,�J--7Q <br /> Describe Material and Procedure <br /> I hereby agree to comply wit all laws Ad regul ions 6f fbe-- San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAIS <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION' <br /> PRIOR TO GRO12ING ANO A Y,7NAL INS CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> INSPECTION BY DATE j0- 7, ,7-?R INSPECTION BY DATE -15--Z <br /> 11 f <br /> E H 1426 Rev. 1-74 ��/� G� 1/77 ' 2M <br />