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f <br /> SAN JOAQUAN-LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> c� Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;7_,2e-2,6 <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 /> t I <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name _4LU"A- e>Phone 25-,?;2OT <br /> Address a " �,(J City <br /> Contractor's Name ' License # Phone :Z.7 le3) <br /> .1 <br /> TYPE OF WORK (Check) : NEW WE LL DEEPEN/ / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other'`/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1=7SEWER LINES 160'- PTT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. -of Well Excavation ` <br /> Domestic/private t Drilled Dia. of Well. Casing � <br /> Domestic/public i Driven Gauge of Casing Q <br /> Irrigation } Gravel Pack Depth of Grout Seal d <br /> ` Cathodic. ProtectionRotary Type of Grout <br /> Disposal I Other Other Information12 47i4qL4, <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OR 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 'constructzon. Within FIFTEEN DAYS I <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 notifythem before ' <br /> 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 <br /> PRIOR TO G UTING AND AIMI INSPACT101y. , <br /> SIGNEDTITLE" <br /> D. W i� T PAN 'ON RE S E S IDE ,.. L . <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7�1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE ±NSPECTION BY DATE <br /> E H 1426 `- ° <br />_ .__.... Rev. 1-74 � 3/76 2P+I <br />