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J <br /> 7W SACT JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (Zbg) 466-6781 <br /> APP ICATION FOR WELUICONSTRUCTION OR PUMP PERMIT Permit No. lJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued _ �ry-7> <br /> (Complete In Triplicate) } <br /> .s <br /> .s <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin 1 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. l` <br /> JOB ADDRESS/LOCATION I G 09 p CCENSUS TRACT <br /> .Owner`s Name _ ��rs n ep.u� Phone <br /> t 3 <br /> -'Address ' in City L Q cl <br /> License # Phone <br /> Contractor`s Name �-� %A,%D�_ : <br /> _TYPE OF WORK (Check) ; IdEW WELL 7EEPEN,/_-/; RECONDITION, /�! DESTRUCTION % <br /> —PUMP-INSTALLATION .�r. 'PUMP-REPAIR. / ./__PUMP_ REPLACEMENT_ "7 <br /> Other <br /> f <br /> ft <br /> _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD De+ CESSPOOL/SEEPAGE PIT OT�IBR <br /> PROPERTY LINEAQ�RIVATE DOMESTIC WELL 30! =PUBLIC DOMESTIC,WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . . <br /> Industrial Cable Tool Dia. of Well -Excavation _ f <br /> . _ Domestic/private 7� Drilled Dia. of Weil .Cavin$ ;a <br /> Domestic/public Driven Gauge of Casing '' VC <br /> Irrigation _y( Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection _ Rotary Type of Grout r <br /> ;. V4 <br /> Disposal Other ---Other--Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S t+`je i - ' H.P. <br /> PUMP REPLACEMENT: - F7 State Work Done <br /> PUMP .REPAIR-. " .,_.r-Y.-:/-/—State Work Done <br /> DES-TRUCTION "OF WELL: Well Diameter Approximate Depth�; ' - <br /> Describe Material and Procedure - <br /> , I hereby agree to comply, with-.-all•-lawis "and regulations of the San Joaquin Local Health.Dtstric�t <br /> and the State of California pertaining',to 'or'reguliting well-construction. Within FIFTBEN DAYS. <br />. -after completion of my work on a new well, I will furnish,.the San Joaquin Local Health DistriI ct. <br />"''WELL DRILLERS REPORT of the well and notify them before putt twig the.-well in use. Ne,above <br />�' information is. true to the best,.of-•my-knowledge and belief.. '"I WILL CALL FOR A GROUT INSPECTION. <br />' PEtIOR TO GROUTING AND A FINAL INSPECTION. <br /> U", SIGNED TITLE <br /> DRAWPWT PLAN 'ON RSE SIDE <br /> RDE ARTMENT USE ONLY <br /> "PHASE Ir <br /> APPLICATION ACCEF B DATE :7-2 Z <br /> ADDITIONALCOMMENTS: <br /> PHASE II GROUT iRPECTION y.,,_d. PHASE I F NAL INSPECT OI� _• . <br /> 14. <br /> INSPECTION BY DATE INSPECTION BY3176 <br /> DACE <br /> E H 1426 Rev. 1-74 <br />