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I�Z)43_s <br /> SAN JOAQUIN LOCAL`HEALTH DISTRICT <br /> 05,11OFFICE USE: 1601 E. Hazelton Ave.", `Stockton, Calif. <br /> II. Telephone: (209) 466-6781 <br /> EI. APPLICATION FOR WELLN CONSTRUCTION OR PUMP PERMIT Permit No. 7q._ 5-5- ja <br /> THIS PERMIT EXPIRES' l .YEAR::FROM,-DATE;ISSUED Date Issued <br /> .:,, - r (Complete Iii .Triplicate) <br /> Application is hereby made to the San Joaquin .Local..Health District. far a permit to construct <br /> and/0r .install. the .work herein described. This application is wade in compliance with San Joaquin <br /> .County Ordinance No. 1862, and the Rule and Regulati.ons, of. the.San Joaquin Local Health District.' <br /> 0-2-12 ADDRESS/LOCATIONCENSUS TRACT <br /> _. <br /> Owne�r's Name �j �,�Z25e <br /> Phone�� <br /> Addriss City <br /> Contractor's <br /> T9 � <br /> ContlContractor's Name License I6�-3�phone`7 46 a e��'j <br /> iti <br /> TYPE OF WORK (Check): . NEW WELL /_7 DEEPEN /`7 RECONDITION /? DESTRUCTION /_7 { <br /> PUMP INSTALLATION /_7 ;�PUMP REPAIR PUMP REPLACEMENT <br /> Other /% <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 S <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I- Industrial: ' Cable Tool Dia. of Well Excavation .� <br /> �il, .Domestic%private Drilled Dia' of- Well Casing �. <br /> 'I. Domestic/public Driven Gauge of Casing <br /> 11 'Irrigation' Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection Rotary Type of -Grout' <br /> rG 'Disposal Other Other Information <br /> 1h Geophysical Surface Seal Installed By: <br /> PUMP.�INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:. J / State Work Done <br /> PUMP�IREPA1R:;- <br /> :al <br /> ES TRUCTION OF WELL: Well. Diamet np mate Depth <br /> EIi Describe Material and Pr6c ure ` <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 /> WELLIIDRILLERS 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 /> PRIORS TO GROUPING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 4. — FOR DEPARTMENT USE ONLY -- -•, i <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY .. DATE <br /> ADDITIONAL COMMENTS: <br /> E PHASE II GROUT INSPECTION PHASE INAL PECTION <br /> INSPECTION BY DATE 'INSPECTION BY TE r J <br /> ,} E!H 1426 Rev. 1-74 ,._ 1-74 2M p, <br />