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SAN JOAQUIN LOCAs. HEALTH DISTRICT -- <br /> FOAr FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> " APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit,No. Z 11_71jlo <br /> THIS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to tha 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 /> A20° <br /> JOB ADDRESS LOCATION <br /> _ -.-- - <br /> l _ � �c7 r,� e?� /�+i�/�,.Ao;4-.,x: CENSUS TRACT <br /> Owner's Name _ <br /> S-0 at i i` ✓rn s' _..----- Phone <br /> � - - - n <br /> Address City <br /> d ' <br /> Contractor's Name ,�, License #.Ifg 7W Phone 06 7476 <br /> TYPE OF WORK (Check): NEW WELL/_7 /_7DEEPEN '/7 RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR Y/ PUMP REPLACEMENT 17 <br /> Other <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v\ <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 <br /> �C 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 _ <br /> Type of Pump -- - --- it,....._.._..,._ H.P. 7-r-- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: 7 State Work Done 4 o44) Ave). ✓ -- /4Lwotor, l4r�ew41� ' <br /> DES-TRUCTION 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 /> E q <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 stealth 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 o . my nowt ge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING A FINAL I CTIO . <br /> SIGNED TLE <br /> ` D PLO PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS,: / <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE _ �S <br /> ; t E H 1426 Rev. 1-74 1-74 2M <br />