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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE OFFICE USE: !w 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : <br /> Telephone : (209) 466-6781 QL <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 7 969P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 119-37 <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 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 r CENSUS TRACT <br /> Owner's Name ��� j �. �, D LI ZZ �' __._..._.._, Phone pp ee -- <br /> E3�f�_ <br /> Address r City El e6A.) <br /> Contractor's Name ls � License #c nl Phone <br /> r : <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> t PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 TYPE OF WELL 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 0 <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 /> �� , N <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:! State Work Done "" ,"1- <br /> PUMP .REPAIR: / / 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 Cali-f..ornia 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 my knowledge and-belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTTAG AND A.. FIINSPECTION. <br /> SIGNEDTITLE6,1a. <br /> . (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �j p <br /> APPLICATION ACCEPTED BY � - 2�.•r� may" DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II, RQ, T INSPECTION PHASE' II LVINAL INSPECT ON - <br /> INSPECTION BY A (J , DATE INSPECTION BY DATE 7 <br /> _ E <br /> i 177 _ 2M <br /> E H 1426 Rev. 1-74 _ _ , <br />