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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hnzelton Ave., Stockton, Calif. <br /> �., <br /> Telephone: (209; 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J-/ <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Completf• In 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 aed Regulations of the San Joaquin Local Health District. <br /> "i_ JOB ADDRESS/LOCATION •qaCENSUS TRACT <br /> Owner's Name 17� K"G F4 S lila,-/o n/ Phone 9-,2 P Ali <br /> Address <br /> city _Ecv/oma% <br /> Contractor's Name /t ��oJJ %/„ tU License Phone7yi <br /> TYPE OF WORK (Check) : NEW WELL (,'J DEEPEN /_% RECONDITION /7 DESTRUCTION /-J <br /> i. PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> -+ Other <br /> DIS'T'ANCE TO NEAREST: SEPTIC TANK /!S' SEWER LINES i7.a PIT PRIVY <br /> s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEIQ{PRIVATE DOMESTIC (JELL !Z.IL PUBLIC DOMESTIC WELL � G <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS W <br /> • � Industrial Cable Tool �i <br /> u1 Dia, of Well Excavation <br /> ” e Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven G:iuge of Casing _ /�o PS/ OdL— <br /> Irrigation , r Gravel. Pack Depth of Groat Seal S-e <br /> Cathodic Protection � Rotary T"De of Grout —gl�,,,eAY7 <br /> Disposal Other Other Information <br /> —Geophysical <br /> Surface Seal Installed By: /. ow. <br /> PU*LP INSTALLATION: Contractor _ i{r�_LLL-: _ .y'e �:,•+ ..,��� <br /> Type of Pump S,,t F. 11.P. <br /> JUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done r <br /> DESTRL•CTION 0, ";EJL: Well Diameter --�_^ Approximate Depth _ <br /> Dascribe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di, ic: <br /> and the State of California pertaining to or regulating well construction. Within FIFTEtcv uAYS <br /> after completion of my work on a new .,ell, I will furnish the San Joaquin Local Health District a <br /> :ELL DP'LLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of :) knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN E�PION. <br /> SIGNED _ TITLE <br /> _ _(DRAWPIAT PLAN ON REVERSES IDE) <br /> — , F`R DEPARTMENT USE ONLY <br /> POASE I <br /> APPLICATION ACCLPTED BY - DATE I <br /> ADDITIONAL COMME":TS: <br /> PHASE: I1 GROUT INSPEC' ON , r, PHASE �1-,J//FINAL`INSPECTION <br /> ?NSPECTION BY y ; ' \ {,>>.'_� DA'CE _ INSPECTION BY ,�/fj!,t�: y')ATE %2.L <br /> ,.� b//7 - 2M <br /> K <br /> f' 2426 Rev- 1-74 <br />