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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE: f�1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . re g �rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueS--d-1-24( <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 %/�� - �-7-E-� / r CBNSUS TRACT <br /> Owner's Name /-Z--Ca Phone ' /. <br /> Address f 'Z D <br /> City . . L <br /> ea <br /> Contractor's Name Gc.6/J g 4c /� JL <br /> _ .��� __. l S/ License #2$`ola_7 Phone <br /> TYPE OF WORK (Check): NEW -WELL .f DEEPEN ,/-7 RECONDITION /-7 DESTRUCTION f7INSTALLATION "/ / PUMP REPAIR '/-7—pump REPLACEMENT 17 <br /> .�- Other L_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI;L' PUBLIC DOMESTIC WELL \ <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool - Dia. of Well Excavation '' GN <br /> Domestic/private Drilled Dia. of Well Casing : <br /> Domestic/public Driven Gauge of Casing 12- <br /> Irritation Gravel Pack Depth of Grout Seal Y--o <br /> Cathodic Protection X Rotary Type of Grout ^ <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P 3 <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'REPAIR: /7 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 GROiTTING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE <br /> W PLO LAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � . <br /> d4 <br /> V <br /> APP IL CATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: - : <br /> PHASE II 9=T/ZKSjrZVrfW PHASE III FINAL-IN SPECTI N <br /> INSPECTION hATE - ''1 INSPECTION By DATE r� <br /> E H 1426 Rev. 144 - - r -U75 2M + <br />