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Corn /09410�-, %f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE-. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., <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 F�1 T 1a+,a CENSUS TRACT <br /> Owner's Name ✓ ay 0` AF 4Phone <br /> Address 77kQ` City —iclYo` <br /> Contractor's Name cG4ude&l J M_ License f//f3124--phoneAla Z� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/-7 RECONDITION /-T DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEtzPT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYLINE - 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 /> Domestic/public Driven Gauge of Casing 4 <br /> Gravel Pack Depth of Grout Seal <br /> �( Irrigation of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Jf) `� - H.,P_ na--Type of PumpPUMP REPLACEMENT: / / State Work Done _ qr. G 'PUMP .REPAIR: /�/ State Work Done - �� /� �A- <br /> DESTRUCTION OF WELL: Well Diameter <br /> `1 Approximate Depth s� <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations ovelleconstruction Loci[hinaFIFTEENtDAYS calS <br /> and the State of California pertaining to or regulating <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 kn ledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN 0 TITLE /6f <br /> SIGNE W. PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPE IOC <br /> PHASE II R IN C ION <br /> INSPECTION <br /> BY ' DATE a2 T <br /> INSPECTION BY TE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />