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SAN JOAQUIN LOCAL HEALTH. DISTRICT /,� <br /> FOF. OtFICE -USE: 1601 E. Hazelton Ave. , Stockton, Calif. J -3 <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/,a�- <br /> i� (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 of the. San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name �i Phone -599-2 <br /> I <br /> Address12259 E- No 11,n Aypnup <br /> i� City <br /> I� License # A2 Phone ' 522-902 _ <br /> Contractor's Name Stanislaus Pum 90�, 7 <br /> :II i <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN %J RECONDITION / / DESTRUCTION j-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT X� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f i <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 /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of. Casing <br /> X Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal if Other Other Information <br /> Geophysical i. Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1C / State Work Done _ Replaced Puma _ <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 '-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 od-the well and notify them before putting the well in use. The above i <br /> information is true to the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO CROUTING, AFINAL INSPECTION. THl$ I5 RFADY ICOR , ' CT O <br /> SIGNED . <br /> ;4 13EtAW PT: T PLAN 'ON REVERSE SID ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> / .` A <br /> APPLICATION ACCEPTED BYi1 ,� j DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II •C OU IN PECTION PWAII/F AL INSPECTION, <br /> INSPECTION BY v DATE INSPECTION DATE/,� <br /> 3/76 2M <br />�. E H 1426 Rev. 1-74 <br />