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f' <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> -TOA('OFFICE USE: IZ- 1601 E. „Hazelton Ave. ,'Stockton, Calif. <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-2-110 <br /> THIS PERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7--i7-7Z <br /> (Complete 1n 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 CENSUS TRACT i <br /> Owner's Name �'E fflc� P Phone' <br /> Address �/a City 'S C /9 4 O <br /> Contractor's Name < _5�zKa ,v 4;a 'o,U _— License Phone <br /> TYPE OF WORK (Check) : NEW WELL/_T DEEPEN -/_7 RECONDITION /7 DESTRUCTION 17 <br /> PUNP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / '- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Plt 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 Q <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. Other Information , <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> rType of Pump 5'uf� - H.P. t <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> "PUMP .REPA -7 `Done <br /> _State Work <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 /> aind 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-beat of my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTMG AND A FIM I SPECTION. <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 /> IH <br /> APE Ii GROUT INSPECTION ISA I FINAL INSPECTION <br /> INSPECTION BY .DATE INSPECTION BY4M2M&g== DATE 7 -9. <br /> E H 1426 Rev. 144 1_74 9M <br />