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{ � b3rxe•:�r.�17&o:t�. -eft �_��� <br /> f w SAN JOAQUIN LOCAL. HEALTHDISTRICT o l3ox Io o I <br /> ;FOR OFFICE USE: 1'601 E. Hazelton Ave. , ,Stockton, Calif. / <br /> Telephone: (209) 466--6781 �r*'�*ecq, e,-,�1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. gSJ3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-a(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 9J7 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l 'Alepfa CENSUS TRACT <br /> Owner's Name Phone 3 ® � <br /> Address e7yuG <br /> Citys.e, -P <br /> baaContractor's Name (/r1, _� IkL& License 11.11PhoneFg-(V( <br /> � I <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN /% 'RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK (JK4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION' SPECIFICATIONS a <br /> f <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ri <br /> Domestic/public . i Driven Gauge of Casing $ <br /> —;;�Irrigation —# -gavel Pack Depth of Grout Seal <br /> Cathodic Protection / Rotary Type of Grout ZV off <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractorj, - <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,.REPAIR: /_7 State Work Done <br /> DES•TAUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall laws and regulations of the San Joaquin Local Health istrict <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 a <br /> WELL DRILLERS REPORT of the well and notify them before 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 INSPECT QN I <br /> PRIOR TO G 0 TING AND A FINALIINSPECTION. <br /> SIGNED I TITLE <br /> ' I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR APARTMENT USE ONLY <br /> .PRASE I <br />�APPL�CATION ACCEPTED. BY DATE L? > <br /> Ab,''HIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE JL;)�/FINA INSPECTION <br /> IiNSid'ECTION BY DATE INSPECTION BY DATE /a-d-7`7 ,9 <br /> E H 1426 Rev. 1--74 <br />