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Y6� SAN JOAQNL LOCAL HEALTH DISTRICT / <br /> 76K:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> EI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,6_z�,-a_W <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE -ISSUED Date Issued -7-IJ--2A, <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 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ze ZZ. I[e$'� CENSUS TRACT <br /> Owner's Name z Phone <br /> Address 42-,1G/ 61147R g11R <br /> city <br /> Contractor's Name License #z44 e4.Phone : a <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ RECONDITION � DESTRUCTION <br /> PUMP INSTALLATION - PUMP REPAIR ,/-7—pump REPLACEMENT ` /7 <br /> # . v Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK /,64 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> -- <br /> ;;INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> gndustrial X Cable Tool Dia. of Well Excavation / Z , <br /> Pomestic/private Drilled Dia. of Well Casing <br /> kDomestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal -o <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br />[ PUMP INSTALLATION: Contractor D m 'rzG S"7�°l <br /> Type .of Pump <br /> PUMP REPLACEMENT: %// State Work bone � <br /> r k <br /> PUMPREPAIR: / / State Work Done <br />` 1]ESTRU.CTION OF WELL: Well Diameter W � 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 /> F and the State- of California'.pertaining to or regulating well 'cotistruction...--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 /> inforttiation is true to the•best of my.knowledge and .belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. € <br /> 00. <br /> SIGNED s ``' TITLE00 <br /> , <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE 'ONLY ,. <br /> PHASE I . .-. ., �..�... <br /> APPLICATION' ACCEPTED BY , - DATE ' ' �� <br /> IT . <br /> ADDIONAL commENTS <br /> :a PHASE 11 GROUT INSPECTION PHASE II/FTNAL II/FINALINSPECTIO <br /> INSPECTION BY DATE / ;, INSPECTION BY DATE /G <br /> E Hi 1426 Rev. 1-74.' -R r 4/_75. 2M"`� <br />