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+�fS' SAN JOAQUINfLOCAL HEALTH DISTRICT <br /> P. ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.q —/5 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Bate Issued <br /> (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ .� /V T41Z4K. j,7, )e CENSUS TRACT. " <br /> Owner t s Name f � -1� _ I 14Ild Phone �i (O _ F <br /> Address � cityL <br /> D] <br /> ,�2 Vh <br /> Contractor's Name f j(J/ �•.•D _�,jLIX(6 License # VQ_Rhone 7�-3� <br /> TYPE OF WORK (Check)�: NEW W 7_ <br /> ELL_/ - `DEEPEN / /""RECONDIT N_/ / AESTRUCTION <br /> PUMP INSTALLATION /T/ PUMP REPAIR / / PUMP REPLACEMENT ` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ] ` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE6!;PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS1 <br /> Industrial Cable Tool Dia, of Well Excavation r62.ea <br /> 4-�— Domestic private Drilled", Dia, of Well Casing �t <br /> Domestic/public Driven� Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> w <br /> PUMP INSTALLATION: ContractorAL%j �.3u I <br /> Type of Pump H.P. . �1{1 <br /> 1 � 1 <br /> PUMP REPLACEMENT: Sta-tetiWork D.. one -- - -- -�---r - --' <br /> j, <br /> PUMP _REPAIR: .. / /- -State Work Done_ -- "` <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 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 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 /> PRIOR TO G UTING AND A F1,N4L INSPECTION. f <br /> SIGNED 1,Q ` 7;' ' J _ _ TITLE _� r <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 11 GROUT INSPECTION PHASE III/FINAL INSPECTION ell <br /> INSPECTION BY DATE INSPECTION BY DATE 7-.2—(' <br /> E H 1426 R, tr- -I-7G <br />