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tt/fJ(J SAN JOAQUIN LOCAL HEA'LT'H. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 _7 <br /> _yllrle2 Telephone : (209), 466--6781 <br /> APPLICATION FOR WEUL CONSTRUCTION .OR PUMP PERMIT Permit No. ?z�--- -c � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued��� <br /> (Complete In Triplicate) 7 <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 /> ! <br /> JOB ADDRESS s��-y CENSUS TRACT , <br /> Owner's Name rZ ij a .".5 mil/ A Phone <br /> Address City <br /> Contractor's Name License �� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / J RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST LATION "X/ PUMP REPAIR.// PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES c>Q-f i'IT PRIVY "" <br /> SEWAGE DISPOSA FIELD .. CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY IliNd- PRIVATE DOMESTIC.WELL '"+� PUBLIC DOMESTIC WELL/ P <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECI-FICATIONS <br /> Industrial Cable Tool �Dia. +of Well Excavation � <br /> Domestic/private [ Drilled .. Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack z Depth of Grout Seal �5_471 ,n <br /> Cathodic Protection Rotary .Type of Grout L_ Q <br /> Disposal Other Other 'Information <br /> Geophysical Surface-Seal Installed By: <br /> PUMP INSTALLATION: Contractor � '� �/fi 5 � ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: f / 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 anew 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 GROUTING AND A FINAL INSPECTIO 2/1 /S <br /> SIGNED <br /> W AN ON REVERSE SIDE) <br /> FO PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r? d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/ INAL INSPECTIOby <br /> INSPECTION BY 9*Q DATE .f-�► - 77 INSPECTION BY DATE �3 <br /> ! 3/76 -, 2M <br /> E H 1426 Rev. 1-74 ' <br />