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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <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. <br /> . 11 zy!/4L37o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. -7r- <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 Ruled ��egulations of the San Joaquin Local Health District. <br /> f a h�G s ,Pia <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> Owner P s. Name~ lk E 2G f _ Phone IVZ7 7 9a' <br /> Address WZ•8"]� � <br /> Pd, BN ;pj!2sCity S'�Zn-c_*7nA/ <br /> Contractor's Name License #gj77 Phone <br /> s <br /> TYPE OF WORK (Check): NEW WELL/J-1DEEPENLGF RECONDITION /_7 DESTRUCTION -/_J <br /> PUMP INSTALLATION / UMP REPAIR /7 PUMP REPLACEM$NT f <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES /00 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 <br /> Omestic/private : Drilled Dia. of Well Casing <br /> Domestic/public Driven -Gauge of Casing f , <br /> Irrigation Gravel Pack Depth of Grout Seal _S0 �- <br /> Cathodic Protection Notary Type of Groutf �llTnwrrra _ _ - <br /> Disposal Other -r-Other Informationf' �.-_... :t ;- <br /> . .F,y <br /> GeophysicalSurface Seal Installed By--.) i, <br /> 7k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A r 7 if.P. <br /> PUMP REPLACEMENT: / / State Work Done -.. `;. ., <br /> PUMP-.REPAIR•:­:......,..�--.:..,'/-T—state-WorkmDone~" <br /> ,RES;TRUCTION OF WELL: Well Diameter f 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 wi'll�furntsli kthe�,San.,Jaaquin 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 myknowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNEDTITLE ' ;t,c,Eic' <br /> D W PLOT PLAN ON- REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I j <br /> APPLICATION ACCEPTED BY DATE .2 <br /> ADDITIONAL COMMENTS: - t�7R <br /> PHASE jj GROUT IECTION PHASE II FINAL INSP CTION <br /> INSPECTION BY DATE i- -��- .�- INSPECTION BY DATE <br /> •�y�.,'�"C.'.� 'y - <br /> E H 1426 Rev. '1-74 ) ��' 174 2M ,; <br />