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SAN JOAQUIN LOCAL HEALTH- DISTRICT' <br />" <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. + <br /> Ca <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No.2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 'p-j- <br /> (Complete 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 iri `compliance with San Joaquin <br /> County Ordinance No-. 1862 andtthe Rules and Regulations of- the- San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA/TION 1115.3 ao f� E'l f',{,�/ /n p� CENSUS TRACT <br /> Owner's`Name �,,,J A IV rvi Phone- e7 <br /> Address a _ . . 1Rw- o._ c� Y <br /> Cit �o 0/1 <br /> Contractor's Name 1&i.Uety'rdT._.,..:r•T�lF,�.,..r. -._— License #pZ Phone <br /> !➢�M.n <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP' INSTALLATION I I PUMP REPAIR -/ I . PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY -EINE' ''PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF'WELI; --_` 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 Usk <br /> Irrigation 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 <br /> ._Type -of.:_Pump ._,-, uib�r.rrs�/L-r --- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �T Describe Material and Procedure + <br /> y <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 completiozi '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, rrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I10PECTION. A. <br /> SIGNED - _ TITLE <br /> °-(DIiA T PLAN ON REVERSE 5ID i; <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE 31 <br /> .ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION, <br /> INSPECTION BY DATE - INSPECTION BY DATE/0 -/6-.7 <br /> t <br /> d <br /> E H 1426 Rev. 1-74 3/76 2M <br />