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FOC�� SAN J©AQUIN LOCAL HEALTH DISTRICT <br /> OFF� FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I "I <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26L ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7 -7 <br /> (Complete In Triplicate) <br /> Application is hereby made t� the Scan 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q7fr�'7 CENSUS TRACT <br /> Owner's Name PAyL - Phone , <br /> a City ' L02 <br /> Address a2 0. 7 &:. Q d K suaa Q - <br /> Contractor's Name Lice <br /> ��� �c�i . ..., nse #J7 fQ Phone ',M24207 <br /> TYPE OF WORK {Check): NEW WELL '/ DEEPEN /-7 RECONDITION, DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR '/� PUMP REPLACEMENT <br /> Otherl <br /> DISTANCE TO NEAREST SEPTIC. TANK SEWER LINES PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> "•. L "� PROPERTY LINE ­.,PRIVATE.DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE.. `, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial-7' `Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled.„t:-, ..`Dia.-.,of Well Casing <br /> Domestic/public's Driven Gauge of Casing <br /> Irrigaeios I Gravel Pack Depth of Grout Seal <br /> Cathodic 'Protection i Rotary Type of Groitt <br /> Disposal Other Other Information ” <br /> Geophysical ` ` v Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ,P W <br /> Type sof Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> �PUMP .REPAIRs - ~ _ - /% State Work Done.- <br /> PEST <br /> one <br /> DESTRUCTION OF WELL: WelliDiameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebyagree to comply with all laws and regulations of the San Joaquin Local Health District <br /> g P Y g <br /> { and the State "of Californialpertaining to or regulating well •'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELV bRILLERS REPORT of the well and notify them before putting thd..well. in.use.. . :The above <br /> Leiiiformation is true to- the-best-of- my knowledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> PRIOR TO GROVWNG AND A FIM AL INSPECTION. " <br /> SIGNED TITLE` <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> r: FOR DEPARTMENT USE ONLY '/ <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> HASE II GROUT;�INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION E ! DATE INSPECTION BY DATE -2.A <br /> - 2M,., <br /> .•a 77 �/.7th" n..- 7-_7/. I, ,-, �- .. <br />