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0 <br /> Case 14. SAN JOAQUIN LOCAL HEALTH DISTRICT • v} M <br /> FOR,OF ��- USE: •1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ',(J ar i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District fors 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/LOCATIONp4044 <br /> {ti �- ''j "r,.' •' CENSUS TRACT <br /> Owner's Name b O A U Phone <br /> Address �+!7 . /� o '7 %m SOls rRn6►►L City SO4 <br /> Contractor's Name 04-04l se. License 4 Z1173d�hone i4bt7(r Ui M <br /> TYPE OF WORK '(Check) : NEW WELL / / DEEPEN / 7 ,RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION Z::/ PUMP REPAIR /x/ 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 — iPUBLIC 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/public Driven , ' Gauge of Casing <br /> Irrigation F . 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 E;�ae <br /> Type of Pump ` H.P. ' L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done Xd.J/-x <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 m� work on a new well; I will furnish the San Joaquin Local Health District i <br /> WELL DRILLERS REPORT of the well•and motif them before puttingthe- well in use.. The above <br /> information is true to the best 4f. my kn wle a mnd benldef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NG AND A FINAL I PE CT ION. _ _ _ - <br /> SIGNED y TLE <br /> kDRAIA RLOY PtAN ON REV SE SIDE) + <br /> FOIrDEPARTMENT USE ONLY " <br /> PHASE I <br /> APPLICATION ACCEPTED BY tj DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION* P I ./FINAL INSPECTION <br /> INSPECTION BY IDATE - - INSPECTION B 'DATE- "x.3--7 <br /> i <br /> - . 2m <br /> ` E H 7.426 Rev. . 1-74 t 6/77 <br />