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f <br /> N601 <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOEOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �7 �,./ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. HCl <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 2oZ 06- S T, S ,ESC ALbN CENSUS TRACT <br /> Owner's Name Al- /Q4Li- lAIS — Phone 3 S' :3 0 Z3 <br /> Address S H E V City 2E 5C- I-Ol <br /> Contractor's Name License #2OD 94 <br /> Phone 95/$- Rr <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ff DEEPEN / / RECONDITION /? DESTRUCTION /- <br /> — <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 Q <br /> Industrial Cable Tool Dia. of Well Excavation _ /2 3 <br /> Domestic/private Drilled Dia. of Well Casing /2 kad <br /> Domestic/public Driven Gauge of Casing GA C� <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> _ Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ,VO4Cke <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '""�- H.P. <br /> a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PU'M)? .REPAIR: / / 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 GROUT NG AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAWPL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BYDATE -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA E FINAI, INSPECTION <br /> IidSPECTION BY DATE INSPECTION BY / DATED <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 '� � <br />