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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.-,F-OFFICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 3 f 4d <br /> f THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _. 4 <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 aRegulations of the San Joaquin Local Health 'Dfstrict. <br /> JOB ADDRESS/LOCATION D l3 7 /'��flo �� /+•'� CENSUS TRACT <br /> Owner's Name �,, l� Phone9=3 9S' <br /> Address �� 3 7 a v e_ �, cs� City a j6 <br /> i <br />,i Contractor's Name ¢ .',` _r bvo_.O;. License #XZ QjEtj Phone SZZ/031 1 <br /> I TYPE OF WORK .(Check): NEW WELL AT DEEPEN '/-7 RECONDITION ./_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other J-7 <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK 322SEWER LINES 3 30 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 3301 CESSPOOL%SEEPAGE PIT OTHER ' <br /> E PROPERTY LINE 7,�/PRIVATE DOMESTIC WELL PUBLIC DOMESTIC-WELL= Q <br /> INTENDED .USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable Tool Dia. of Well Excavation rw <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> l " V <br /> DorLestic%nub.ltc,� _� r� __, Driven _ - Gaugeof_.Cas ing. - -- 3 <br /> Irrigation Gravel <br /> Pack Depth of Grout Seal -- <br /> �� <br /> Cathodic Protection Rotary Type of Grout . =_ -_ <br /> JkoVL <br /> Disposal Other Other Information a <br /> Geophysical Surface Seal Installed By: JLvkie +^ <br /> r PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -REPAIR: - ,. /7 State Work-Done- <br /> . <br /> D <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - <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 anew 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 INSPECTION. <br /> PRIOR TO G&ETING jAND,A FI SPECTION. <br /> SIGNED TITLE <br /> D W. PLAN '0N REVjf1kSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /�� DATE / <br /> ADDITIONAL COMMMTS: <br /> PHASE II GROUT INSPECTION. PHXSEI.III/YINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE { <br /> Lp H 1426 Rev. 1-74 - a �7 <br />