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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0_fi".*.OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 10� .,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date lasted� <br /> (Complete In Triplicate) 1 __L Cl 2-oo q? <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 /> JOB ADDRESS/LOCATION 7" -in := `-w j `` CENSUS TRACT <br /> Owner's Name L. Dai Fort* � Phone 2 <br /> Address .. 1130 W. Moutoray City Sto6kton <br /> Contractor's Name W. Go Noesk Ino. License # 209124_ Phone9.48 '8811 <br /> TYPE OF WORK (Check): NEW WELL '#V DEEPEN J7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7-pump REPLACEMENT /7 <br /> . Othdi <br /> O <br /> DISTANCE TO NEAREST SEPTIC TANK%2- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER w <br /> _ PROPERTY LINE —PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 10-i4ah j <br /> Domestic/private Drilled Dia. of Well Casing _ inoh � F <br /> Domestic/public Driven Gauge of Casing Class 160lastia . <br /> Irrigation - Gravel Pack Depth of Grout Seal 4o ft. <br /> Cathodic Protection '"'��` Rotary Type of Grout Bentenite <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Oyaor <br /> Type of Pump Gentrl al, ahallow well. H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> ES-TRUCTION OF 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"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in use.. The above A <br /> information is true to the-best Of- my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR GgOUTjNG ' A 1<INALAINSPECTION. <br /> SIGNED t ,ft.,G TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 to <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION J <br /> INSPECTION BY DATE INSPECTION BYE DATE 2p <br /> E H 1426 Rev. 1-74 f 11/7 K. 9M <br />