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. � c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: C14601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> .ZZ-Z fig 4j,. <br /> HIS 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 /> Count Ordinance No. 186 ark the ules an Re ulations the Sa Joa a Local Health District. , <br /> y S !-J�/4� 1I3 /J/ <br /> JOB ADDRESS/LOCATION NSUS TRACT <br /> Owner's Name _ - �,(�� ��/�f7 jos Phone <br /> Address City <br /> Contractor's Name ,( M147p/_�) b,ejL1&j6 _ License #2VVy< PhoneX,q-��ZZ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_/ RECONDITION /_� DESTRUCTION'/� <br /> i� PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <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 t CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation /2 /A/. <br /> Domestic/private Drilled Dia. of Well Casing 8 /A/ <br /> Domestic/public Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 91 fyr�X <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: /� 4iWT <br /> . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - L/l�_rn� �,(��C . _. H•P <br /> PUMP REPLACEMENT j_/ State Work Done— <br /> PUMP -REPAIR: <br /> onePUMP .REPAIR: /�/ State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter - -t Approximate Depth \ <br /> Describe Material and Procedure <br /> L <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,.Sa_n Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> ,5 information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE <br /> DRAW�PL T PLAN ON REVERSE SIDE _ 1' " <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY DATE Z -��2 <br /> ADDITIONAL COMMENTS: ' <br /> PHASE _II GROUT_INSPECT E _,,t _PHASE III/FINAL .INSPECTION. <br /> 122 <br /> INSPECTION BY DATE K/� I INSPECTION BY C' ' DATE L <br /> -E H 1426 Rev. 1-74 x/76 2N <br />