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SAN JOAQUIN LOCAL HEALTH DISTRICT D <br /> FOE OFFICE USE: 1601 E.. Hazelton Ave..,- Stockton, Calif. r <br /> " <br /> Telephone: x`(209)`•466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z-gaga-s1° ; <br /> THIS ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2-ap-7.d <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, j <br /> JOB ADDRESS/LOCATION �' A441*4 hJ gw CENSUS TRACT f <br /> Owner's Name 'T� J_e_ C )-c - Phone <br /> Address City <br /> Contractor's Name License �� j4n2 <br /> ''Phone <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN ;/�/ RECONDITION DESTRUCTION. /_7 <br /> AL <br /> PUMP INSTLATION -/ / PUMP REPAIR /5e/7—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO- NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 <br /> Domstic/p <br /> Driven <br /> e of <br /> Irrigation <br /> Gravel Pack Depth of Grout gationSeal <br /> Cathodic Protection ^ ' Rotary Type of Grout. v ' <br /> Disposal Other,. Other Information <br /> Geophysical _ �.a Surface Seal"Installed_By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .PUMP .REPAIR: / State Work Done te��Fw Oars DESTRUCTION OF WELL: Well Diameter Approximate Depth �V <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, knowledge and belief. I WILL CALL FOR A GROUT -INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPTk_CTrQNoj <br /> SIGNED ITLE, <br /> Q�AW. + T PLAN ON RWERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /,z -- 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II FaZOUT INSPECTION TP /F AL INSPECTIOtYINSPECTION BY DATE INSPECTTION.BDATE <br /> f�� 2M <br /> E H 1426 Rev. '1-7 - <br />