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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0�_ YOFFXE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.71-,0 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .�h-7� <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. l 2 and ncg�utto � of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (f ' jr�� itA_/ 46, CENSUS TRACT <br /> Owner's Name Phone p 7 <br /> Address WCity( TAe__11 <br /> N <br /> Contractor's ame � Q �-/0.. y,/ <br /> } ����J _ (%G!'" License �}yz�OC Phone�� / „3 4, <br /> z <br /> TYPE OF WORK (Check) : NEW-WELL / / DEEPEN / / RECONDITION /—/ DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR /—/ --PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER 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 <br /> Industrial Cable Tool Dia, of Well Excavation n ` <br /> �mestic/private Drilled Dia. of Well Casing - A 1 <br /> Domestic/public Driven Gauge of Casing [ !_, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> ]Disposal 10ter Other InformationGeophysical S ace Seal talled n : <br /> PUMP INSTALLATION: ContractorG !J 64? G,r <br /> Type of Pump ZL5 H.P. <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLS REPORT of the well and notify them before putting. the we11 'n use. The above <br /> informatio is true to the best f m know dge and belief. I WILL C OR A GROUT INSPECTION <br /> PRIOR TO Gh&INC A FINAL I PE <br /> SIGNED TITLE <br /> DRAW LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY VDATE 2, <br /> E H 1426 Rev. • 1-74 6/77 2M <br />