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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 QFF_.ICE`USE• /1601 E. Hazelton Ave. , Stockton, Calif. 1-7- <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 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�Q�J el <br /> FtoOlU CENSUS TRACT <br /> Owner's Name � I /v (��`�te Phone 0030 ""•30Q <br /> Address �o� iC./(/�j� City <br /> Contractor's NameL/�,�L`I L�l�rGT License �� Jl�hone�3-`156 <br /> TYPE OF WQRKY(Check) : -NEW,WELLfZ—DEEPEN-/Z/-PRECONDITION"/_/— ESTRUGTION f�J <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY -- y <br /> SEWAGE DISPOSAL FIELD 1 `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 <br /> Drilled Dia. of Well Casing <br />- _ Domestic/public. ... - - . . Driven LC <br /> �_�.... -�_ �; xge- ox=Gasimg - ~. <br /> Ix�iga ion Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout _ "V <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: ;"`:'lam"`�� s, <br /> PUMP INSTALLATION: Contractor '"(�j1J�;- / e 7-a7f7 <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-:REPAIR - - /�[—State.,Work"Done <br /> DES-TRUCTION..O.F 'WELL: Well Diameter ' •` r V 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 comple of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRI RS PORT of the we and notifythem before <br /> putting the well in use. The above <br /> inform ion is rue to the b of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GROU NG D IN 'SPRCTTnN <br /> SIGNED TITLE <br /> W PIS T PLAN ON ITVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE F �7 � LI //f�`r/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHA&E II PJRQUT INSPECTIONP E I NSPECTI N ' <br /> INSPECTION BY DATE INSPECTION ,BY DATE <br /> �ilJfL�-I zO e G.eoi.•s�.sa� r <br /> E H 1426Rev. 1-74 — 3/76 2M <br />