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SAN JOA UIN LOCAL HEALTH DISTRICT;- <br /> FOE <br /> ISTRICTfFOE OFFICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 S� / <br /> �4XPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �j 7 <br /> t <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 ' erein described. This application is made in compliance with San Joaquin <br /> County brdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S�WCk &Z�fCg CENSUS TRACT <br /> Owner's Name �11r �/�' !`?!. +�'E/�TS,. Phone . a levo <br /> Address, i 6f , <br /> �f City /1✓,19/�7".�C219 <br /> ConCractor''s Name Ax 0 ZZ, C License # Q Q 7 Phone 9V,?e0e17 <br /> TYPE OF WORK (Check) : 14-EW WELL ,X DEEPEN / / RECONDITION / / DESTRUCTION /-J <br /> PUMP INSTALLATION 0 PUMP REPAIR / J PUMP REPLACEMENT /-J <br /> Other <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 . Drilled Dia. of Well Casing °` ® , . 4 <br /> Domestic/public._ Driven Gauge of Casing _ / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> CatbD4ic -Protection Rotary Type of Groutre2dLC/'c`�%E <br /> -Disposal I Other Other Information ' .. <br /> ' Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor [ , C �Z <br /> - Type of Pump r ` H.P. fi��: <br /> PUMP REPLACEMENT; State Work. Done <br /> PUMP .REPAIk: /:7/ State Work Done <br /> DES-TRUCTIONI; OF WELL: Well Diameter Approximate Depth <br /> �;. Describe Material and Procedure - <br /> I hereby agtee to comply;l'with all laws and regulations of the San Joaquin Local Health District <br /> arid4the State of California pertaining to or regulating well'construction. Within FIFTEEN,:DAYS <br /> after comptioof my <br /> ln <br /> work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS iREPORT 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 GRQU G AND A AL INSPECTION. <br /> SIGNED TITLE 4 <br /> 1� -,(DRAW PLT PLAN''ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'�ACCEPTED BY ;� DATE ,1� <br /> ADDITIONAL COMMENTS: <br /> PHASEGRQU INSPECTION P S II/FI AL INSPECTION OR _ _ <br /> INSPECTION BY 444C4&jAAytjDATE r2 7- 7 INSPECTION DATE <br /> ■ <br /> /7 <br /> 1426Rev-. -I--74' <br />