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4 <br /> - SAN JOAQUIN LOCAL-HEALTH DISTRICT - <br /> FOAjOFFICE USE: 1601 E. Hazelton:Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-r�l74` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> - .Y (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct k <br /> and/or install, the..work herein described, This application is made in compliance with San Joaquin <br /> County Ordinance No. -1862 andithe Rules and Regulations of the San Joaquin Local Health Dist ct. <br /> JOB. ADDRESS/LOCATION t 2 ' <br /> _� CQ CENSUS TRACT <br /> Owner's Name � � O p , EG�� r ) Phone <br /> Address Cit <br /> r <br /> Contractor's NameX0_4 CX _ 8.�L 4fl�lL�. _.� License #fig 9�-8'b? � <br /> -- Phone <br /> p i <br /> 1 <br /> TYPE OF WORK (Check): NEW WELL /H DEEPEN- /_7 RECONDITION /_7 DESTRUCTION %f .. <br /> PUMP INSTALLATION / /.Pump,REPAIR /% PUMP REPLACEMENTf <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _,5_e9 SEWERLINESPIT PRIVY , r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMEST� WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE riTXPE .OF',WEVLY' /" 'CONSTRUCTION SPECIFICATIONS <br /> Industrial *_,Cable `Too_1 Dia.. .of. Well Excavation{ <br /> �- . „_ <br /> Domestic/.private Drilled Dia. <br /> K... � Of`Well Casing €_ 61, +.. <br /> Domestic/pub'lic Driven Gaage of Casingtj ,4. <br /> Irrigation ^ Gravel. Pack Depth. of Grout Seal , D/ <br /> Cathodic Protection �] _ Rotary Type of :Grout * 9:2f& <br /> � <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed B U, G <br /> PUMP INSTALLATION: Contractor <br /> Typp-o£: Pump . " <br /> PUMP REPLACEMENT: i / / State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done 4r_ <br /> PES4£RUCTION 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- new-well,_.I will furnish the_San, .Toaquin_,Local.Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in,,use.. . The above E <br /> information is true to the-best of myknowledge and belief. I WILL CAtL FOR;A-GROUT INSPECTION <br /> PRIOR TO GROMOG ANP A MAL INSPECTION. r E 4 <br /> SIGNED TITLE <br /> -- -� ^^-'—°-- (DRAW PLOT PLAN ON REVERSE SIDENZ' <br /> PHASE I :FOR DEPARTMENT USE ONLY ; t <br /> APPLICATION ACCEPTED BY —e <br /> DA—Ti -47 ,—Z 7 <br /> ADDITIONAL COMMENTS: . ! :a a: f <br /> PHASE'II GROUT INSPECTION P I FINAL_INSPECTION <br /> ,INSPECTION BY- a DATE L INSPECTION BY NDATE - g <br /> t E H 1426 L Rev. 1-74 'i-74 2M <br />