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l <br /> _ SAN .7gAQUIN LOCAL HEALTH DISTRICT To <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rI l <br /> F <br /> ! 7 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 /> z <br /> JOB ADDRESS/LOCATION _21131 L6M 0 AJ CENSUS. TRACT ' <br /> Owner's Name LES Phone <br /> Address 61 L k,1, r/ 1 <br /> City �'C��`�-Q <br /> d <br /> Contractor's Name .S7` ' M �Vj b rjf STQ License # Z 43S'Shone S ZZ-f62% <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN :/_/ RECONDITION / / DESTRUCTION /_ _ <br /> 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 o � <br /> Industrial `Cable Tool ? Dia, of. Well Excavation \�F <br /> Domestic/private Drilled ; Dia. of Well Casing <br /> �f <br /> Domestic/public "Driven Gauge of Casing 4 <br /> Irrigation rGravel Pack Depth of Grout Seal <br /> Cathodic Protectioni—��Rotary Type of Grout <br /> Disposal 10ther: Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contracto�� <br /> Type of Pump i LA- - / --� - H.P. — <br /> PUMP REPLACEMENT: - <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: �Well5Diameter , s t Approximate Depth <br /> 1� -'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 willufurnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of .,the well and notify them bdfore 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 GROUTING AND'A..FINAL INSPECTION:'`_ <br /> SIGNED TITLE 0 <br /> ' -(DRAW PLOT PLAN ON REVERSE SIDE) ! <br /> . " FOR DEPARTMENT USE ONLY <br /> PHASE I ''• r { <br /> APPLICATION ACCEPTED -BY W_ DATE 1 r <br /> ADDITIONAL COMMENTS: <br /> T " -PHASE 1I GROUT 'INSPECTION. PHAS VII/FIN4 INSPECTI N - <br /> INSPECTION BY DATE ^I INSPECTION x DATE 2 <br /> 6/77 <br /> E H 1426 Rev. - I-74 <br /> J2M <br />