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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> k F0E-OFFICE USE: 1601 E. Hazelton A`fve. , "9tockton, Calif. <br /> 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 p > <br /> (Complete In Triplicate) <br /> Application is hereby made t0 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 6" SM)XJ c.L.- CENSUS TRACT <br /> O"er's Name �.► �R.L� !-(Z.4 C•�t"�IRE rT1 Phone a ? - 76 �-V <br /> Address /7?-0Y /LJ ,L.. V?-d '' , City ( , . <br /> Contractor's Name. 01421- It A,#" eAAJ Z)A _._ pr_,A1_ (U, License #AZ?74D <br /> Phoned3,2- ?if/ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN _f RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION PUMP REPAIR /% PUMP REPLACEMENT f-7 7 <br /> Other f%; / r <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY i <br /> WialvF v SWAGE- ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> OPERTY"LINE - PRIVATE DOMESTIC WELL- .PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial l . y>.Cahle-_T-ool--_ ,,.-:Dia..-of-Well�Excavatio �,_ M1 0 <br /> Domestic/private t Drilled Dia. of`Well Casing I <br /> Domestic/public ! Driven Gauge- of Casing p occc <br /> IC`rrigation i =Gravel Pack Depth of Grout Seal <br /> -,.Cathodic Protection :Rotary Type of Grout 1114 <br /> Disposal :Other Other Information . " <br /> Geophysical "Surface Seal Installed B : <br /> PUMP INSTALLATION: . Contractor•- 4r ~ <br /> Type of Plamp v1 H.P., 26--_ <br /> PUMP REPLACEMENT: / / State Work Dane {� <br /> PUMP REPAIR: / / State Work�Done <br /> DESTRUCTION OF' ELL: Well Diameter Y <br /> +-- _ Approximate Depth Jf l <br /> Describe Maw rial and Procedures <br /> I hereby agree to comply withlall ,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.-bistrict a <br /> WELL DRILLERS REPORT of the well and notify them bef6re putting the -well in use. The' above <br /> information is true to the best of my..knowledge and •beiief. � �I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO-GR04yANG AND A FI [INSPECTION. <br /> SIGNED exse hC :., � i -TITLE A <br /> i DRAWI, T' PLAN.: ON'RE ERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , - ' DAT4,"Z724 7E <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHA II IAL INSPECTI N <br /> INSPECTION BY DATE' INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 .. . <br /> 3/76 2M <br />