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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No6. 54,E <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Ciereby 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 .Dis,trict. <br /> led- �4 00`cE'�a"z` C f u!a , <br /> JOB ADDRESS/LOCATIONr,&I el . 10 v t CENSUS TRACT_ " <br /> Owner's Name -- aef law 'k1 Phone <br /> • )/?- 1 t <br /> Address �7Y 'Ei _ A aj 7 (1 _ L City <br /> Contractor's Name > - License # $/.3 Phone62 <br /> ,Z <br /> TY OP WORK (Check) NEW WELLj� DEEPEN -/7 <br /> I DEEPEN -j7 RECONDITION %f DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other / / — <br /> tiDISTANCE TO NEAREST: SEPTIC TANK /Dd SEWER LINES loo PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER s <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 \1 <br /> Domestic/private Drilled Dia. of Well Casing _ j 7-v <br /> Domestic/public Driven Gauge of Casing `6? �l <br /> Irrigation Gravel Pack Depth of Grout Seal J7 ,V <br /> Cathodic Protection p/ . Rotary Type of Grout <br /> Disposal Other Other Information " . <br /> Geophysical Surface Seal Installed Bge ,r"i' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , /7 State Work Done <br /> PUMP ,.REPAIR: F7 State Work Done <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 GRPUTING AND AFINAL INSP I <br /> SIGNED i' TITLE <br /> DMA LOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 <br /> ADDITIONAL COMMENTS: <br /> PHAS GRO NSPECTION PHAS I FIN INSPECTION / <br /> INSPECTION BY ATE 2 71 INSPECTION BY _Ubo&j DATE 12e -7 6 <br /> E H 1426 Rev. 1-74 4/75 2M <br />