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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 'FOR-2 ICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �460' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued = -T7 <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 �,��f�/Q �L /,? CENSUS TRACT <br /> Owner's Name Z24tz1,0 c�.,�/vim �trPhone <br /> Address yl� �.�.rr � City7.�✓.c ., ,E.c <br /> Contractor's Name License ��, Phone ! <br /> TYPE OF WORK (Check) : NEW WELL P DEEPEN%/ RECONDITION /_7 DESTRUCTION /^T <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 _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - - Cable Tool Dia. of Well Excavation '�� SB i_Z4 H "� <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 1, e- ArAZA44 _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:,V <br /> PUMP INSTALLATION: Contractor Al 9,-- a! <br /> Type of Pump H.P.• <br /> _ Lw ? 7 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> DESTRUCTION 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 Mstxict <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 es of y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A FI S ON. <br /> SIGNED TITLE wt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY. DATES�? <br /> ADDITIONAL COMMENTS: <br /> PH4E IL_,P_L0Uj INSPECTI N PRARPIIIMNAJ, INSPECTI0 <br /> INSPECTION BY/ DATE .6- 7 INSPECTION B -DATE o <br /> r` <br /> la l? 7 - PO dC_ ` I_�' 177 2K <br /> E H 1426 Rev. 1-74 �)'�''�� �'�6�� `/7 � <br />