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� < SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: tiff 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/ _a - <br /> ;�� r' (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. 186/2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / / '� �� ( ..�c CENSUS TRACT <br /> gZ3- 3 1X5- <br /> Owner's Name Phone g 2 3-11 4J t E <br /> Address <<,(1 City 2n_t <br /> Contractor's Name 4 , License # Phone . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /S DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSL <br /> SEWER LINES 5-0 PI <br /> SEWAGE DISPOSAL FIELD 'tCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS• �. <br /> Industrial Cable Tool Dia, of Well Excavation / (� <br /> I,—Domestic/private c..--Drilled Dia. of Well Casing p` <br /> Domestic/public Driven Gauge of Casing ( \� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _-Rotary Type of Grout �_�a. .< <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: a1115 ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> rES-TRUCTION OF WELL• Well Diameter 4? Approximate Depth <br /> Describe Material and Procedure ,2 ,nz <br /> SCJ < 4,1r.! CzCu, <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAY <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 G UTING AND FIML INSP ION. <br /> SIGNED _ . TL > <br /> D W 2d,e-41 I <br /> P AN ON RE'VE SIDE .' <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II fROUT JNSPECTIONPHASE /FINAL INSPECTION <br /> INSPECTION BY ATE /yif��Z, - 76/ INSPECTION BY DATE - 7 <br /> E H 1426 Rev. 1-74 1_e� 'G_ea ' 1�4^',,/ AH 11,-,4f11,-,4f , 3/76 <br />