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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> OFFICE USE: 1601 E. Hazelton Ave. ,Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11,l <br /> THIS PERMIT ~EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued <br /> (Complete Id Triplicate) <br /> Application is hereby made to the San Joaquin Local Health. District for a permat. 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 ��1 �L[, CENSUS TRACT <br /> Owner's NameT F� -f��� Phone � -3� -� <br /> Address WO Lf E RbA-D > City f 1542 / 64�'1.1i <br /> //�� y )) I /� License �� JJ d Phone <br /> Contr <br /> actor's Name is V �i� 6 L�.� `.{ U�_��Ek`- © . [e Z � <br /> 5 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL YK DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> k Ofher#/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> G PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well CasingT� <br /> •. Domestic/public_ t Driven Gauge of Casing Z , <br /> Irrigation t Gravel Pack Depth of Grout Seal �tl <br /> Cathodic Protection Rotary Type of Grout uHr-Pr <br /> Disposal = � , ° Other Other Information -- <br /> Geophysical"* _ ' Surface Seal Installed By: _ <br /> BUMP INSTALLATION: "Contractor 0,.'; ` <br /> Type of Pump _ H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> l � <br /> PUMP REPAIR: / I State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 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 th best of my- knowledge and' belief I WILT:-CKLL f'OR A' GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA N INS CTIUN. <br /> S I GNEDI TITLE <br /> - . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I ._ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � �11 DATE <br /> } ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - ,may 7- _ INSPECTION BY /",,! DATE ? -2± 27 <br /> 2M <br /> E H 1426 Rev. - I-74 <br />