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C t j 6Y/'-SANN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ave. Stockton, Calif. . <br /> FOA�O CE USE: 1601 E. Hazelton , <br /> Telephone: {209? 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No•7y� � <br /> " THIS PERMIT EXPIRES 1 YEAR FROM DATE I5�SUED Date issued ]_�1Y <br /> (Complete In Triplicate) <br /> Application is hereby <br /> made to the San Joaquin Local Health District for a permit !a o Jl�� � <br /> and/or install the work herein described. This application is made is complicace with <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District- <br /> County <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 'M <br /> 1 Phi a-sem! 11 <br /> owner's Name <br /> d _ iG{�I1 G�p City <br /> Address f� 6 <br /> � 01 License <br /> Contractor's N J <br /> TYPE OF WORK (�„`Iseck): NEW HELL /7 DEEPEN /7 RECOIr'DITIO�N� DESTRUCTION <br /> PUMP INSTALLATION 7 PUMP REPAIR & PUMP REPLACEMENT I T <br /> Other /7 M. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEXIER LINES _ _ PIPITPRIVY <br /> ` SEWAGE DISPOSAL FIELD CEPOOL/SEEPAGE PIT <br /> OTS <br /> S` <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC D701ESTIC WELL <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind►.ittial Cable Tool Dia. r ' Well Excavation i <br /> ;[ Domestic/private Drilled Dia. :[ well Casing � <br /> -- Driven Gauge of Casing <br /> Dowsric/public ! <br /> Gravel Pack Depth of Grcut Seal <br /> Irrigation 4 1M <br /> ' Cathodic Protection Rotary Type of Grout M <br /> f Disposal Other Other Information ^ Jh <br /> Geophysical Surface Seal Installed BY: <br /> F gg J <br /> 22 <br /> Vii. P PUMP INSTALLATION: Contractor � v" H.P. � r <br /> y Type of Pump ` <br /> IS <br /> PUMO' REPLACEMENT; L7 Stats Work Done (� <br /> puM P.REAIR:P <br /> LST State Work Done "� 1 s �e, <br /> lilt <br /> ESApproximate Depth <br /> TRUCTION OF WELL: Well Diameter j� <br /> Describe Material and Procedure i <br /> I herejy agree to`comply with all laws and regulations of the San Joaquin Local Heal^h District. <br /> -md the State of California pertaining to or regulating well construction. Within FIFTEEN DI <br /> y <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 /> ku ledge and%belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the-beat of gay <br /> PRIOR IC1 ING AND A FINAL P N TITLE A fjW <br /> : <br /> r D _H P PLAN ON FRSE SIDE <br /> FOR DIT USE ONLY <br /> PHASE I DATE L <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COM?ENTS: P S� _i FINAL INSPECTION k <br /> PHASE II GROUT INSPECTION I14SPECTION BY %/ 'r'� 3✓- <br /> INSPEGTION BY ..-_— °.." DATE---~-.__- 1r.-� �'l-j- <br /> i <br /> I-74 2H1 <br /> E H 1426 Rev. 1-74 <br />