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I C'd �bv'•,�1r/1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' f'Og+flFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 43 <br /> Telephone: (209) 466-6781 <br /> AP �ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z _I <br /> THIS PERMIT EXPIRES: 1 YEAR FROM DATE ISSUED Date Issued, <br /> (Complete -In Triplicate) d SO( - 2-s, O- 2-S' <br /> Application is Hereby made Ito 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 Joaquil <br /> County Ordin ee-No. 1862,.a_nd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ? S _ qlCENSUS TRACT <br /> Owner's Name � Phone <br /> Address d rr D City !G <br /> Contractor's Name License # !jjU'3Phone �,y'74y' <br /> ,r <br /> x TYPE OF WORK (Check): NEW WELL/? DEEPEN17=-RECONDITION /7 DESTRUCTION <br /> PUMP, INSTALLATION /7 PUMP REPAIR LF PUMP REPLACEMENT f7 <br /> x Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. . PUBLIC DOMESTIC WELL <br /> INTENDED USE' jTYPE OF WELL CONSTRUCTION SPECIFICATIONS Z <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domes Pic/privateµ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ..� )c, Irrigation - Gravel Pack Depth of Grout Seal <br /> Cathodic,.Protection Rotary Type of Grout •� <br /> Disposai ' Other Other Information <br /> Geophysical Surface Seal Installed BY:.. <br /> PUMP INSTALLATION: Contractor C7/tt} ,� <br /> Type of Pump - <br /> H.P. <br /> PUNP. REPLACEMENT: /_7 .State-.M rk Done <br /> yw <br /> PUMP :REPAIR: .. � / '4'State Work Daae .- „�., t�-P •�-- J <br /> ,. <br /> ES.,TRUCTION 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 /> k 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•best-of.-mowledge and belief. I WILL CALL'FOR A 'GROUT INSPECTION <br /> E PRIOR TO 4RUJING AND A FINAL IN6P CTI0 <br /> SIGNED _ IdL� <br /> TITLE �, r <br /> {DRA LO PLAN ON TITLE <br /> SIDE <br /> R DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE .�("�7 7 <br /> a ADDITIONAL COMMENTS: .-- <br /> ` PHASE II GROUT INSPECTION PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE - <br /> 3 <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />