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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFIAve. ,, <br /> FCE USE: 1601 E. Hazelton Ave. Stockton, Calif. 1 ° <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 J'jfk 4Qt'vi.Pr e P Al1'C4- IT44 1A41-kX CENSUS TRACT <br /> Owner's Name1310 N eju; Phone <br /> Address 11-9t-f City «, <br /> / License # 1�i )_Phone G j 2.. �$, <br /> Contractor's Name _ Lk�na�� i� /J)h �iMa �Q• �. - <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL 5i7 DEEPEN/ / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 Q� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -_-- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER----- <br /> PROPERTY LINEICYPRIVATE DOMESTIC WELL '""PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSf� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,fes <br /> Domestic/public Driven Gauge of Casing Ufa .cACIAe <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -- Rotary Type of Grout <br /> Disposal Other Other Information 2 ` Prits is <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> 1 <br /> PUMP .REPAIR: / / State Work Donee <br /> DESTRUCTION 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 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 G TING OD A,F7NAL INSPECTION. <br /> SIGNED j TITLE <br /> . D PLAN ON REVERSE SIVE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� <br /> APPLICATION ACCEPTED BY �C,% DATE �^ --- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' II/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �- <br /> 3/76 <br /> E H' 26 Rev. 1-74 <br />