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' 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� 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 InAcompliance with San Joaquin <br /> County'Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - ,. , � � .,� = ,� ,Iw. 1:�; SUS TRACT u <br /> Owner's Name •,...'o �.1 0aC-1C Phone ' <br /> Address f-7 e- -C-3, Nj r,,r City <br /> Contractor's Name 4 e�� +. S <br /> „�'�.._ �r�.ae'.,_.,,_... License �'�'���rv�if�. Phone a_�'7.,t - <br /> TYPE-OF WORK (Check)°-4—NEW�WELL-ZL,7 DEEPEN '-/7- RECONDITION /?�DE5�UCTION j_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/_7 PUMP REPLACEMENT 17 <br /> Other /_7 <br />{ DISTANCE TO NEAREST: SEPTIC TANK `01'0SEWER 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 a� <br /> Industrial Cable <br /> Do Tool Dia. of 1E Excavation on <br /> Bomestic/private Dr.ilee_ -casing <br /> atic/ ulbic <br /> v-, <br /> Driven Gauge of Casing <br /> Ile. Irrigation - 4!S Pack Depth of Grout Seal <br /> Cathodic Protection X - Rotary Type of Grout ' 7 �3 :rf �'�; 77 <br /> Disposal Other Other Information' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor ZE�(_ _ <br /> Type of Pump H•P. '.31r 4Z� <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 /> F 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 F'IF'TEEN 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 /> linformation is true to the best of my knowledge and belief. I WILL CALL FOR,A ,GROUT INSPECTION <br /> PRIOR TO GROUTING ANDd A FINAL: 1INSPECTION. <br /> SIGNED C :fit,.. TITLE )aJ _ <br /> j DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION'-'ACCEPT A091-11V077DATE �2 -I- ZZ <br />, ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIAS MAL JNSPECTION <br /> 4INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - f -�• .T�_ _ L/75 2M _ ;_� <br />