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- 0. d SAN JOAQUIN LOCATE HEALTH DISTRICT -J- <br /> F� FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,1�_6 3J`� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 �� ST At 7,/( CENSUS TRACT s <br /> Owner's Name �r���e AYA 40 40/OV Phone <br /> Address S . *I� City GGA <br /> Contractor's Namel--S 7�0�,Vw License # 1!?-4? Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION /-7 DESTRUCTION f <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 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 R <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> 'Ge ophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto %��� Ole <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /X/ State Work Done <br /> PUMP :REPAIR: L7 State Work Done <br /> ,RES-T RUCTION 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 the-best of- my knowledge and be. ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G ANDA FINAL INS N. <br /> SIGNED <br /> DMKPIff P N REVE SID <br /> k-IFOR DAPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA,SU III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - (? <br /> E H 1426 Rev. 1-74 1-74 2M <br />