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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FFOS rOFFICE USE; - <br /> ' / , ST C 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> , F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ` 5�9� ! <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. :A862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 740-9 S D Sfi ►� CENSUS TRACT <br /> a <br /> Owner I s Name H As LOOL LO P 7 Phone6 Z1 - 0760- <br /> Address' s City <br /> 'Contractor's Name <br /> License .4 Phone <br /> TY'E OF WORK (Check): NEW WELL DEL�'EN /� RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP' ItEPAIR /� PUMP REPLA <br /> 0the�/—J _ ---..3 �... T. CEMENT*/_f <br /> DISTANCE TO NEAREST: SEPTIC TANK y- SEWER LINES <br /> D.. Ix PRIVY ; p <br /> SEWAGE DISPOSAL FIELD, C2 CESSPOOL/SEEPAGE PIT;/7/ONk' OTHER <br /> PROPERTY LINE 20PRIVATE DOMESTIC WELL r PUB3rIC'DOMESTIC WELL}�^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -.2!� Domestic/private Drilled <br /> Dia. of Well Casing �t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -_.Gravel Pack - Dep.th -_f -Grout Seal <br /> _ <br /> E <br /> _ Cathodic Protection. Rotary Type ,of Grout - t <br /> Disposal I Other <br /> ,�,�,� Other Information •}v <br /> Geophysical Surface Seal Installed B NF_= <br /> PUMP INSTALLATION: Contractor 0VV/VE _ <br /> Type ofPump LLD EL.L-- i . <br /> H;P. <br /> PUMP REPLACEMENT: State Work Done f <br /> PUMP :REPAIR: _ <br /> /7 State Work .Done <br /> S`T ell Diamete� - ... r .. i <br /> scribe Ma erial and Procedure Approximate Depth '-�- <br /> I hereby agree to comply with alltilawg an&-ir'egula.tions of the an Joa ui € <br /> and the State of California pertainingyti or regulating well construction.LoWithingFIFTEFdi1tDAYS <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 TOG UTING AND A FI AL INSPECTION. <br /> SIGNED - <br /> Tk I ; v ��;a`�TITLE - 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE .-` - -- - - <br /> PHASE I FOR JDE&ETMENT USE ONLY <br /> .1 <br /> APPLICATION TION ACCEPTE BY <br /> ADDITIONAL COMMENTS: DATE 7- �g: T✓ <br /> PHASE II GROUT INSPECTION -� <br /> INSPECTION BY PHASE III/FINALINSPECTi N <br /> v DATE INSPECTION BY DATE / n <br /> E x 1426 Rev. 1-74 <br />