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Cv 1rA'9 SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> R FOFF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> X APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) 0847-C)C-t'v-2,-a <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I mr + m �i�✓ CENSUS TRACT <br /> i r - <br /> Owner's Name Phone <br /> r I <br /> Address 9 7 S,L <br /> c��.�� QA►a City <br /> Contractor's Name License OE1 �3 �y��phone cam, -74 G <br /> TYPE OF WORT{ (Check): NEW WELL / / DEEPEN/% RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT /7 .� <br /> Other/ / <br /> U1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4z" <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER g� <br /> PROPERTY LINE - PRIVATE DO:NESTIC WELL . PUBLIC DOMESTIC WELL 'V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> IrrigationI Gravel Pack Depth of. Grout Seal j <br /> Cathodic Protection ! Rotary Type of Grout <br /> Disposal 1 Other Other Information j <br /> Geophysical I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump AH.P. <br /> .PUMP REPLACEMENT: / /,', State Work Done <br /> PUMP .REPAIR: T <br /> / State Work Done ✓ _- -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 weil 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE 00. <br /> SIGNED - TITLE {�ror. <br /> PLAN ON EVERSE SIDE) '�-` ^�' <br /> R iDEPART T USE ONLY \ <br /> PHASE I <br /> APPLICATION ACCE F}L Q 4sf DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASZ II ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY1 ,.,_ DATE <br /> ___ E H 1426 Rev. 1-74 3/76 2M. 1 <br />