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jr <br /> ' i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k'OE.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Z$�r���iJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I '(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District4j or 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 yew/ CENSUS TRACT /00'-?-2_ <br /> Owner's Name1011, ,rL Phone <br /> Address 3 ' A/AJ l n�J �'�sV�€Q4,1� City <br /> Contractor's Name 1"IV V lG 5' La, Alco �� License # 2I3 Phone <br /> TYPE OF WORK (Check) : NEW WELL5y DEEPEN / / RECONDITION / / DESTRUCTION /_7 S � <br /> Two "V045. PUMP INSTALLATION / / PUMP REPAIR / / FUMF REPLACEMENT /7 - -N <br /> j ri S/a 11 other <br /> DISTANCE TO NEAREST: SEPTIC TANK S'00 SEWER LINES `O0 FIT PRIVY p <br /> SEWAGE D'ISPOSAL4 IELD N f} CESSPOOL/SEEPAGE PIT D OTHER � # <br /> PROPERTY LINES PRIVATE DOMESTIC WELL�ad ) 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 <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical t Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor IXO# , 62-3-?,03 3 <br /> Type of Pump iU/_/0/tJc _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done s <br /> DESTRUCTION OF WELL: Well Diameter Approximate' Depth r <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 DAIS <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 i tr e to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR R �N AN A N NSPECTTON. I <br /> SIGNED- TITLE' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS. II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2' <br /> ,f 77 2M <br /> E H 1426 Rev. 1-74 _�___ _ - . .___ -- _. ��' <br />