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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 Issrzed <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 an(Lthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '' orti-) --)f I'r°eriCh Cc : d .� CENSUS TRACT <br /> - - 7s t s1 <br /> Owner's Name -toc >ton _ s ter 11.s:'Ll riet Phone <br /> Address 2,5 6 Vre,.iont City L toc'::tan <br /> Contractor's Name , E-zinings jros. rilZin C �. Inc. 29 013 5�}5-1 1 85 <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL T17 DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /~ / PU1fR' REPLACEMENTy <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY II *�/10 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ---_ 14ll, <br /> PROPERTY LINE - _PRIVATE DOMESTIC WELL ___ PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONS`i"RUCT- ON SPECIFICATIONS <br /> Industrial_ _ Cabl.e Tool Dia. of Well Excavation <br /> Domestic/private � Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel_ Pack Depth of Grout <br /> Cathodic Protection - Rotary Type of Grout cef`lc-nt-q sr�r mix- <br /> Disposal <br /> x-Disposal --X Other Other Information ' " a - y <br /> G .O-P ys ,c .lt Surface Seal I. islailec By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <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 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALINSP�F�CTION <br /> SIGNED w�,_..'-I`. s>., ti. . �.:w. z...x+�: IT' <br /> by TITLE "C . <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 GROiJT INSPECTT.ON PHA ES III/FINAL IN�ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E B 1426 Rev. - 1-74 �,�/7 2M <br />