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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Q <br /> Telephone: (209) 466-6781 - rr <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,7.2-3z z,�e` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,5— 25 <br /> 71 O�sET _ (?Ey✓.� (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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C V� Ne)f ` ,yr,l / CENSUS TRACT 2S7410-01 <br /> Owner's Name )7�9y)ws- <br /> Phone a 91 e 4 <br /> Address City IG� <br /> -� P <br /> � <br /> Contractor's Name �( �y ��� License' ,*''_973 Phoxl�N ./� <br /> ' 4. - '^•.y. ."a',�� .ani ... --a—rrSMv� +�'r — - <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> O <br /> r Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing <br /> j Irrigation - Gravel Pack Depth of Grout Seal ". <br /> f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMA'•' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> E <br /> PUMP REPLACEMENT / / State Work Done <br /> s <br /> 'PUMP .REPAIR: /�' State Work Don 't- `'" <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 regulatingtwell '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 /> r PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED n - TITLE �a <br /> DRAW';PL T PLAN ON REVERSE SIDE) 7', is <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I =. <br /> APPLICATION ACCEPTED BY DATE 3--Z J`'?7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FIN INSPECTION- <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E Hm1426 Rev. . 7476 <br />