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A,/ SAN JOAQUIN LOCAL, HEALTH DISTRICT V1 -77 <br /> r <br /> O OFFICE" 1SE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued -15-7 7 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismade 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 �pU i ! A4 j 1y&jr6jy WUS TRACT 203 c sy '1 7 <br /> Owner's Name E Phone - <br /> Address _ l y.?� .S 2£&e S4 _ Al(,_ �. City. -.-. - <br /> Contractor's Name � Q Lz:�G/_ a,11,_e4e License 4L3 � Phone_�yy�;C/.�ZS <br /> i - ` <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL. X DEEPEN ./—/ RECONDITION /_7 DESTRUCTION. /_7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 S <br /> Other /_/ U <br /> DISTANCE TO NEAREST: SEPTIC TANK _-:;�9p f SEWER LINES Cpp PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT --- . OTHER <br /> PROPERTY LINE S-PPRIVATE DOMESTIC WELD*,PUBLIC DOMESTIC WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation Vi/ " <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 --- <br /> Disposal Other Other Information - . <br /> i <br /> Geophysical. Surface Seal Installed By. Q . <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump •: - H.P. <br /> PUMP REPLACEMENT: " / / State Work Done ` <br /> 5 <br /> PUMP :REPAIR: / / State Work Done <br /> E�FRUCTION OF WELL: 'Well Diameter i Approximate Depth " <br /> _ Describe Material and .Procedure <br /> Y ; . <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 t es4PTYI <br /> a- and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING D A 0N:� " <br /> SIGNED ` .TITLE i � <br /> (DRAW PLOT PLAN ON. REVERSE ,SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED .BY ` DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I LI/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY&4DATE <br /> _-_� E H 1426 Rev. 1-74 <br />