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abed V - _._SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FOF�rOFF C SE: 1601 E. Hazelton.Ave., .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL,CONSTRUCTCION OR PUMP PERMIT Permit No. 7�.s°-46 4 <br /> s7z-/0 , <br /> THIS PERMIT EXPIRES 4­YEAR FROM DATE ISSUED Date Issued AZ— 2c <br /> (Complete 1n, 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 Rule and.;Regulations of he .San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATT / �2_ �� CENSUS TRACT <br /> Owner r s Name Oty' y Phone <br /> Address ✓ <br /> Contractor!s Name CPLicense 914;)-37_3r Phone ae5F� <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION 1-7 DESTRUCTION � k <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Odder 1 1 <br /> DISTANCE TO NEAREST: SEPTIC TAN �'�— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -PRIVATE DOMESTIC WELI:- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ✓ Cable Tool Dia. of Well Excavation <br /> 1 <br /> Domestic/private Drilled Dia. of -Well Casing 2 <br /> Domestic/public Driven Gaugeyof Casing <br /> L--' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � 1,� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V?Z-T;/`}. <br /> Type of Pump f -e,� 7Tyo3v H.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP=!-REPAIR:• p-— - - - - <br /> - -� - Skate--Wank--Dane.- <br /> &TRUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribMaterial and Proce ure <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 best of myknowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION., <br /> SIGNED TITLE _ t <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '19 9-7`/ <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 ��� � —��'`'/.� 1-74 2M <br />