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`ZoI7f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> uj IyyU//� //«t.c�cr. <br /> FOE OFJUSE: 1601 Hazelton Ave. , Stockton, Cal: � '�' <br /> .`Telephone: (209) 466-6781 'l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 lq7/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued // 7'7 7 <br /> (Complete In Triplicate)Applicamade 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 S o So, CENSUS TRACT <br /> Owner's Name �/ �7 �oNeTittt Ph <br /> Address �_ 2� 3 X Lo../rE Rd/ City �_ Sc41e,v <br /> Contractor's Name ��vt2d 7� L/ ni A, Jaye License 1j_727/1�1 Phone <br /> TYPE OF WORK (Check) : NEW WELL L/ DEEPEN/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / UMP REPAIR / / 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 LINPRIVATE DOMESTIC WELL ELS PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation 1,21) LQ <br /> }' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, . Depth of Grout Seal /n <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " yJf A <br /> Geophysical S y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District ll ' <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 he best my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TIg2 AND tZFA& ON. <br /> SIGNED ZZ 110 456 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY T DATE — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE AIIJFINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY r a >r_tDAT � - - '� <br /> 44 DATE.; <br /> _ <br /> E H 1426 Rev. 1-74 1177 <br />