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SAN JOAQUIN LOCAL HEALTH DISTRICTy <br /> FOE�^ FFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. # <br /> � <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permi6''No.7_Z-/�77 , <br /> (, THIS; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> /� l x } (Complete In Triplicate) <br /> Application is hdreby 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 f j/G' U '/�/, I ,`�y,,, J�rA •'�u., c,. CENSUS TRACT ' <br /> Owner's Name o v e�+ •, Phone r�,`f 71 <br /> Address `1/U U •,o ���/1 City <br /> Contractor's Name ��n n •'-, S �3n�� w� �J� //r-,f License # 29 Phone �/� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /�•--x <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 O O,-I.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation _//I„G <br /> ` •X Domestic/private [ Drilled Dia.. of Well Casing 6° .,c <br /> Domestic/public i Driven Gauge of Casing /Gy w” / <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection f ' Rotary Type of Grout o <br /> Disposal I Other Other Information e.ct <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of H.P.Pump <br /> PUMP REPLACEMENT:, <br /> State Work Done ' <br /> PUMP .REPAIR: State Work Done <br /> G✓ I Ta <br /> �WEL�L Wel ]ianeyid roximate DepthDESTRUCTS <br /> Describe Material. and Procedure <br /> 1 hereby agree to comply,with,all laws and regulations of the. San Joaquin Local Health District <br /> and the State-of-California pe'rtainirig to or -regulating"well-constxiictlon: Within FIFTEEN-DAYS <br /> after completion of my work on a new. well, I will furnish the San Joaquin Local health DistrictPa <br /> WELL DRILLERS REPORT of the,we' ll and notify them before putting the well .in use.. The above i <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 FINAILINSPEC`IION:, <br /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E �7 I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: A � <br /> PHASE II GROUT INSPECTION PHASE II)E/FINA II/FININSPECTION <br /> INSPECTION BY DATE (/ Z- INSPECTION BY /ytz't DATE/ <br /> ir V vt <br /> ' <br /> E H 1426 Rev. - l-74 �l�lT br�_�` fl � �J <br />