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'no tit SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK.OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S/tea <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedfn2_9 7,S-~ <br /> (Complete In Triplicate) e <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 / �' Ltaeli4040ac�= tip �/_ �, CENSUS TRACT <br /> Owner t s Name 4Phone <br /> Address �v ft1 Da� '7 City C] �c - <br /> Contractor's Name S B pd. i � License # 3 71_j`Phone <br /> TYPE OF WORK (Check): NEW WELL,-/-7 DEEPEN /7 RECONDITION /7 DESTRUCTION j j <br /> PUMP INSTALLATION -/ / PUMP REPAIR -&� PUNP REPLACEMENT /-J <br /> Other 1/7 . .. . . . . <br /> i <br /> DISTANCE TO NEAREST: SEPTIC ,TANK 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 + Cable Tool Dia. 'of Well Excavation" � <br /> Domestic/private I. Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel, Pack Depth of Grout -Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal- I Other Other Information ' ' <br /> Geophysical Surface Seal Installed By:' <br />­PUMP INSTALLATION: SA <br /> Contractor AO FVVLA_ <br /> Type of Pump .e ✓' ill <br /> H.P. <br /> PUMP REPLACEMENT: , / / State Work bone . <br /> PUMP ,REPAIR: <br /> IXI State Work Done haa <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 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."iil-use.... The above <br /> information is true to- the-best-of my.-knowledge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T0 GNG AND A FINAL INSPECTION. <br /> RO <br /> i SIGNED ME - � <br /> k <br /> DRAW T P ON REV SE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY 4DATE <br />' ADDITIONAL COMMENTS: Cz <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY34DATE- --7F- <br /> E H 1426 Rev. 1-74 1./7C ou <br />