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- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> h FOE OFFICE USE: a 1601 E. Hazelton Ave. ,,_Stockton.,_...Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR Wkft CONSTRUCTION OR PUMP PERMIT Permit No. -799 <br /> ii <br /> iITHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7,7-.Z7 <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 trade 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 7 f✓^�, CENSUS TRACT <br /> Owner's Name 7ed ,S' IIZ A 6atLaPhone <br /> Address ,11A PP City <br /> Contractor's Name II S` License #2685-1 Phone <br /> TYPE OF WORK (Check) : ANEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION <br /> �J <br /> [PUMP INSTLATION REPAIR / / PUMP REPLACEMENT <br /> AL <br /> t 4300 her <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> FROPE ftTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> INTENDED °USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l+ <br /> Industrial ` Cable Tool Dia. of We11 Excavation <br /> Domestic/private 'Drilled ` Dia. of Well1, Casing <br /> Domestic/public j� Driven ` Gauge of Casing•-_ <br /> Irrigation Gravel' Pack Depth of, Grout ,Seal <br /> k Cathodic Protection Rotary, ' Typ vof of, <br /> ` "' <br /> f <br /> Disposal s `- ;Other o Other Information t' E <br /> Geophysical.p ' ' .* Surface -Seal Installed By: <br /> I <br /> Ai <br /> i' <br /> PUMP INSTALLATION: Contractor `�v,t, CR ri6 761 <br /> rL�,: � <br /> 1,Type of PumpE r �' - _—� -- H.P. <br /> t PUMP REPLACEMENT: / / State'Work Done .,_.. <br /> PUMP .REPAIR:' State Work"Done"" <br /> I it i; ,•r . ' , <br /> DESTRUCTION OF WELL: jjWel1 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I%ereby agree to Comply with all laaw6 and- regulations of the San JoaAuin Local Health District <br /> and the"State:bf Cal form°a pertaining to or regulatingtwelk�;construction. Within FIFTEEN DAYS <br /> € �,. <br /> aftecomp�letion ofjmyxjwork on anew well, I will furnish the San Joaquin Local Health District a <br /> r� <br /> G WELL,DRILLERS REPORT of the well and ffcatily them}aefore °:putting the .well in use.. The/above <br /> information" is true, totthe best of my knowledge and belief. I WILL CALL FOR A GROUT.INSPECTION <br /> PRIOR'S-T04 GROUTING ANI) A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE STE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r ' DATE: ,� _ . <br /> `APPLICATION ACCEPTED BY <br /> v <br /> ADDITIONAL COMMENTS: 'f <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY s Ji DATE INSPECTION BY r I DATEe�� 0 <br /> �f ]/77 _ 2M <br /> E H 1426 Rev. 1-74 <br />