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e'd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01;_6FF CE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -P-<-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7,.2-2-7,r <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 N'o. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> So-.* AA r <br /> 30$ ADDRESS/VOCATION raK W a P ��np <br /> CENSUS TRACT -_ <br /> Owner's Name =Q4 ot_142 &top a <br /> f «" '�10 Phone <br /> Address G "L �i City <br /> Contractor's Names License # "a224-fhone -cAC ?6?6 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION S PUMP REPAIR/7 PUMP REPLACEMENT /7 <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 <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 <br /> >c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �{ <br /> Disposal Other Other Information. <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a Cr. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP / / State Work Done �f�J "'"�'- _. <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 Distri <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 in use... The above <br /> information is true to the,best-of. mv knowl and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING MD A FINAL. TNSPE 0 <br /> SIGNED ITLE <br /> �. PLAN ON REUME SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 7 Z t <br /> ADDITIONAL COMMENTS: Sj <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r <br /> E H 1426 Rev. 1-74 r _ kf75 2M <br />