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SAN-JQAQUIN`-LOCAL'HEALTH DISTRICT -- -- <br /> FOR,rOFFICE USE: 1601 E. Hazelt'on`Ave. , `Stockton, Calif. <br /> Telephone:. (209) 456-6781 <br /> }� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2.Z-- 5- <br /> l <br /> I z <br /> THIS PERMIT EXPIRES IfYEARr=FROM DATE ISSUED Date Issued <br /> ;(Complete In Triplicate): .. <br /> Application is hereby made to the San Joaquin Localjlealth 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.. 1$52 and the Rules !and .Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION1,zz pID <br /> ck CENSUS TRACT <br /> Owner's Name c, Phone <br /> — s <br /> : Address-�� /S"100F-=�at�C c � �� `1 -e-" - - �---�•�., r� <br /> sa City [ <br /> Contractor's Namew �,_ L <br /> 'license d Phon r3 S/S <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /� RECONDITI44 UCTION �f <br /> PUMP INSTALLATION /&% PUMP REPAIR / PLACEMENT <br /> Other /7 <br /> A <br /> DISTANCE TO NEAREST: SEPTIC TANK S --INES FIT PRI <br /> SEWAGE DISPOSAL F CESSPOOL/SEEPAGE IT OTHER \ <br /> PRO TY - PRIVATE DOMESTIC WELL. PUB IC DOMESTIC WELT, <br /> -INTENDED USE N. OF WELL C'.ONSTRUCT ON SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Exca ation <br /> _ .Domestic/priv a Drilled Dia. of Well Casi E <br /> Domestic/public Driven <br /> ii-f�r,�TM - -. .. Gauge of Cas.it�g��. -- <br /> Irri ation -_-w� _�, - <br /> g .T Gravel Pack Depth of Grout Seal <br /> .Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> f <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: F <br /> Contractor fj 4 <br /> c <br /> Type of Pump 5 r <br /> I A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: i <br /> /7 State Work_ Done <br /> ES:TRUCTION OF WEL Well Eliamater <br /> 1proximate Depth j <br /> esti <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 constru tion. Within FIFTEEN DAYS ; <br /> after completion of my work on a new well, I will furnish the San Jo quin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the .tL <br /> l in use.. The above <br /> information is true to the-best of. my.knowledge•-and belief. I WILL FORA GROUT INSPECTION { <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. j <br /> SIGNED I <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE�- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �: } DATE <br /> ADDITIONALµCOMMENTS: - 1 <br /> PHASE IANAI GROUT INSPECTION IIF AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B.Y <br /> DATE <br /> E'H 1426 Rev. 1-74 <br /> i_7i ')M <br />