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q <br /> pL <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "FO .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> LTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r7� <br /> (Complete In Triplicate) 257~ ZPr'D—G/ <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 /> Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> uz7 <br /> JOB ADDRESS/LOCATION T �tw� �J2c1 �� " +'" CENSUS TRACT <br /> Owner's Name �u,,•ti :.w Lc, i ��- Phone <br /> Address QcityP.i- <br /> j Contractor's Name� 04'!S 4t.1 w,. 4 QDA License —Phone 5-T <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> l PROPERTY LINE - PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial l Cable Tool Dia. of Well Excavation <br /> Domestic/private., Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> r � <br /> PUMP INSTALLATION: ` , Contractor 04-Scs,,�� l�nat; c e� �P • -- <br /> ..Type of Pump T. <br /> e s H.P. <br /> PUMP REPLACEMENT: ,-, / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter ` Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws andire,gulations 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 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 GROUTING AND A FINAL INSPECTION. y <br /> � -TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN- ON REVERSE SIDE)._. <br /> FOR DEPARTMENT USE ONLY �j <br /> f PHASE I DATE � 7/J <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION P SE I /FIN INSPECTION ' �i <br /> I INSPECTION BY . DATE/(/ INSPECTION BY <br /> ATE7_ r 7b <br /> 1/M . 214 <br /> E H 1426 Rev. 1-'74 — -- <br />