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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> .. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUER Date Issued <br /> "?_/(a <br /> /(a <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 3` 131 Vd .Un ' affi*Wgidof , <br /> Owner's Name ` r 1 c, 1 n _ Phone <br /> Address 11299 _ .td/' �2&- - - - -- City ow <br /> Contractor's NameHem)I vl f���l''1 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION1-7. _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_SAL f SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPO -FIELD_60�+—CESSPOOL/-SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial If Cable Tool Dia. of Well Excavation <br />^ � Domestic/private - : Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing _ I�Q jA( <br /> Irrigation i Gravel Pack Depth of Grout Seal CTD' <br /> Cathodic Protection jX_ Rotary Type of Grout <br /> Disposal . 1 Other Other2Information <br /> ✓ <br /> ri <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contraftor i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: S;tate Work Done vsft <br /> State <br /> �tmateATR=; Work' D <br /> -o <br /> n <br /> e <br /> r+�`^-,..�.. -�1�.-r•-M.�-k-�+e�r�r---� -_. _ — -._— ---- _ `.�-. �. <br /> - <br /> DESTRUCTION OF WELL: Well Diameter - _ Approximate Depth <br /> Describe Material an&�Procedure ,. <br /> I hereby agree to comply with fall laws and regulations of the-Sari Joaquin Local Health Distrtct <br /> and the State of California pertaining to oriregulating`'�rell'''construction. Within FIFTEEN DAYS" <br /> after completion of my work on, a new well', I will-furnish- the San Joaquin Local Health District art <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 1 <br /> PRIOR TO GROUTING AND :A FINAL INSPECTION <br /> SIGNED + F. TITLE L=� (a 79 i <br /> D .PLOT P ,-ON-REVERSE-SIDE)--77�i <br /> FOR DEPARTME4T USE ONLY.._. <br /> i <br /> PHASE I -y <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t <br /> j <br /> PHASE II GROU INSP CTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,/ DATE 7,Z!5� <br /> b,�77 2M <br /> E H 1426 Rev. • 1-74 , <br />