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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&('OFFICE USE: Ol E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z�,Lev <br /> r THIS PERMIT EKpIRES 1 YEAR FROM DATE ISSUED Date Issued 33 -, s— <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 La 1,57,-2 Jc, O /,t CENSUS TRACT i <br /> Owner's Namex /F I Phone <br /> S(� <br /> Address Gd � / <br /> City fL..L_ �/ j? <br /> Contractor's NameA R// S'VA License i ,2�W �2 ' <br /> TYPE]OF WORK (Check): NEW WELL 17 DEEPEN /7 RECONDITION /=7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /W7 PUMP REPLACEMENT O <br /> / <br /> Other 7 <br /> .. — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p- <br /> �� Industrial Cable Tool Dia. of Well Excavation a ( r <br /> Domestic/private. ' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP °INSTALLATION: Contractor `/ `jj <br /> Type of Pu H.P. <br /> PUMP `'REPLACEMENT: / / State Work Done G <br /> PUMP '.`REPAIR: /7 State Work Done <br /> r <br /> ES-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 /> 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 FORA GROUT INSPECTION <br /> PRIOR TO GR0 ING AND N INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE �� <br /> FHASEI FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE] /7s^ <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTIOIJ PHASE III FINAL INSPECTION <br /> INSPECTION BY. DAT INSPECTION BY v DATE <br /> E H 1426 Rev. 1--74 ,, <br />