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"d SAN JOAQUIN LOCAL HEALTH. DISTRICT r / <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave-. "Stockton, Calif. <br /> T 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 <br /> C�' E�r`T74rq v£ (Complete In Triplicate) 22.0- f3o-o <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San Joaquin . <br /> County Ordinance No. 1862 the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION Alk, A ACENSUS TRACT ' <br /> Owner's Name Phone <br /> Address 6W City <br /> ; F <br /> Contractor's Name License # 0ib Phone ' _ Q / <br /> i' <br /> TYPE OF WORK (Check) ; NEW WELL J DEEPEN/ J RECONDITION /_/ DESTRUCTION /-7PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT j <br /> Other J-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYRl,�� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. .of_ Casing. Yom./�_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor S r_7 <br /> ,Type of Pump z2zd.16141 1 H.P. `€ <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ i t <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4s <br /> 4 <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 at <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 FINAL MS?EC7ION. <br /> SIGNED TITLE <br /> W P T PLAN ONFAVERSE SIVE) <br /> FOR DEPARTMENT USE ONLY { <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: a ' t <br /> PHASE II GROUT INSPECTION PHASE KIPFINAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION B --7 2 <br /> - V <br /> E H 1426 Rev. 1-74 <br />