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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OB-OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S <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 / v :/c �' W�llWeee�= i yk Al F,,,/- .TT j � CENSUS TRACT <br /> 1 <br /> Owner's Name C* e.O,r rt (Jl Br ezic Phone // <br /> Address /4Z�o ;-d/ �i// 1��kjyo� � City <rdb <br /> Contractor's Name '-f4Bul License # 37,zTThone VZ 1--7674. <br /> � a <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION/-T DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR I—] PUMP REPLACEMENT /7 <br /> Other #/ / <br /> i <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 <br /> Industrial 4. Cable Tool Dia. of Well Excavation" <br /> Domestic/private i Drilled Dia. of Well Casing \ <br /> Domestic/public 1 Driven Gauge of Casing v) <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other Other Information" <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ax/ �_a"- <br /> Type of Pump 4-✓P A0, 0, H.P. <br /> PUMP REPLACEMENT j—/ State Work Done <br /> PUMP '.REPAIR: /jC/ State Work Done a r d<r Aw ,)a—tye Q d.o. - h&,3 `_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth (� <br /> Describe Material and Procedure \ <br /> I hereby agree to comply withlall 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.-iii-.use.. The above <br /> information is true to the-best of my knowledge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND A FINAL INSPECTION. <br /> SIGNED �i D TIEae 1' , <br /> DRAWT P ON SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> SCATZON All BY i DATg Iii S �5' <br /> 'IONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE- / - a-7S <br /> E H 1426 Rev. 1-74 ou <br />