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Co Id SAI vAQOIN LOCAL HEALTH DISTRICT <br /> FO- RVICE USE: 1601 E. Hazel COn, Ave. , ,Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 '9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11 - Y T <br /> THI'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) Z03 - oSa-- 3( <br /> Application is.Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein destribed. This application is made in compliance with San Joaquin ; <br /> County Ordinance No. 1862-Ind'the Rules and Regulations of the San Joaquin Local Health District. i <br /> 1lIG — D- 7 r'�2.�'7 Seo• <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name` "<��iB1' Phone <br /> j <br /> Address / /-� �9 :( f��a+ ,.r/�i �� City 1/�cci� aCi[ <br /> Contractor's Name ISM License # �jrofhone G-j- Z <br /> TYPE OF WORK (Check); NEW WELL L DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /% PUMP-REPAIR PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY h <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 t Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> - Domestic/public Driven Gauge of Casing <br /> x Irriga—tion Gravel Pack. Depth-of Grout-Seiki-Z <br /> r— Cathodic Protection Rotary Type' of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> 'PUMP INSTALLATION:'d Contractor <br /> Type of Pump H.P. $Vl� <br /> PUMP REPLACEMENT: `�L/ State Work Done <br /> 'PUMP REPAIR: / State Work Done ' <br /> ;PESe UCTION OF WELL: Well Diameter - Approximate Depth <br /> i, Describe Material and Procedure <br /> a. <br /> �Iheraby,agree `to, comply with all laws and regulations of the San Joaquin Local Health DistTict' , <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 b'est' of,my, knowledged-b lief. I WILL CALL FOR A GROUT INSPECTION <br /> jghPRIOR TO GROU ING AND A FINAL INSPE& N._ ITLE <br /> MIGNED <br /> (DnITLOT ON REV SE SIDE <br /> , /F/OR DEPARTMENT USE ONLY _ <br /> Pu 4 I ` J - /f /t/ s <br /> LIGATION ACCEPTED. BY (� / FDATE 7�' �� <br /> LI <br /> ,)�MITIONAL COMMENTS: <br /> PHASE'. II GROUT INSPECTION :; " P rFIN INSPECTIO <br /> INSPECTION BY DATE .. INSPECTION BY DATE <br /> 1/77 2M <br /> e E H 1426 - Rev. 1-74 <br />