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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. rj� y q3 <br /> Telephone: (209) 466-6781 (( 7 J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> l (7/ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,Mo (Complete In Triplicate) ZS - 2�r- <br /> �5f .�. ,-� 7 C73 <br /> Application is hereby-madePto '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 Joa uin Local Health District. <br /> I <br /> p <br /> JOB ADDRESS/LOCATION �2 �S, o% �"i } C V�, �p w" sill, <br /> CENSUS 'TRACT <br /> G <br /> Owner's Name <br /> t ' - N � Phone <br /> Address /1)/g,( ,ff (Y/9,l /F _-- City <br /> Contractor's Name Ove, License #2 ,`f0 f.3 Phone 6--,? lei,3 <br /> TYPE OF WORK (Check) : NEW WELL V DEEPEN '/ / RECONDITION /_/ DESTRUCTION ./_7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> w Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I _ SEWER LINES APIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMES'T'IC WELL : f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing V64 ay__ <br /> Et Irrigation• Gravel Pack- Dep th-�-of'i Grout--Seal i✓e,�%�s'�'^" <br /> ,Cathodic Protection Rotary Type of Grout 10- <br /> tDisposal Other Other Information <br /> Geophysical Surface Seal Installed By: - �- <br /> PUt1P INSTALLATION: Contractor " / ,Ozl <br /> Type of Pump B e - = s' 6f I`'/3 / H.P. /P4 <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DE•S;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> I -hereby agree to comply with all-laws-afi2d,,regulations of the San Joaquin Local Health District <br /> and the State of California .,;pertaining;to or,regulating well-construction. Within FIFTEEN DAYS <br /> afterr completion of myI_work on a new well,;;Irwi11 �'-urnish-i-he San. Joaquin Local Health District a � <br /> WELL DRILLERS REPORT`df 'the well and�'notafy' them before putting the well in use. The above <br /> information,is rue, to, the;,best--of.my- n•owled:ge jAd belief. t I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO A AL I1,NPECWN. j- <br /> SIGNE /� z - ? 'TITLE <br /> (DRAWzPLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE'.ONLY c <br /> P SEI "' ` :? DATE yT ��7 <br />;APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE N INSPECTION BY/,/ DATE//- <br /> 1177 _ . 214 <br /> E H 1426 Rev. 1-74 <br />