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�. SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 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 42-36-7(/ <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 OFF iY CENSUS TRACT `5 <br /> Owner'a Name zv1I2 t�1 - ,- ---.,---- Phone F3.-S, !� 7 <br /> Address --- 161-3 722miz �1L�� : City ' <br /> Contractor's Name F -,' -7-�,0. License # Wz1j1jPhone <br /> 12 Lt 5L-j d <br /> Tin OF WORD (Check); NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / I FUME REPAIR / / PUMP REPLACEMENT <br /> Other 1-7 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK -Z SEWER LINES 2619 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 Cable Tool Dia- of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing P ' <br /> _ Domestic/public Driven f.• _ Gauge of Casirig <br /> Irrigation Gravel Pack ' Depth of Grout. Seal 'a <br /> _ Cathodic Protection � - Rotary -Type of Grout <br /> Disposal Other Other Information, .�%Sl.I/6 _ j$, jm <br /> Geophysical Surface Seal Installed By: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done q ei V .., k+ .,I <br /> PUMP .REPAIR: /-7 State Work Done <br /> ,PES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyYwith 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 puttingthe 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 INSPECTION. <br /> SIGNED _ TI �. <br /> Wit <br /> PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> :p APPLICATION ACCEPTE BY DATE 1 6 3 <br /> ADDITIONAL CO <br /> OUT INSPECTION I NAL INSPECTION <br /> TNiSPECTI BY DATE �/�_'�/-� iNSPE DATE <br /> F, E H 1426 Rev. 1-74. ._ 1_7412M <br />