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OF SAN JOAQUIN LOCAL.-HEALTH DISTRICT f <br /> FOR FFFICL` USE: y 1601 E. Hazelton Ave. , Stockton, Calif. (� <br /> i Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 11 <br /> & I <br /> . . . . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f"� -7 <br /> 4 . (Complete In Triplicate) <br /> Application is hereby made tothe 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. G <br /> JOB ADDRESS/LOCATIONynCENSUS TRACT <br /> Owner's Name Phone ( <br /> ,I <br /> Address-13 <br /> tt—.. M e., } <br /> City <br /> Contractor's Name P&8ALA <br /> � .} License # Phone <br /> �y - 4 h <br /> TYPE OF WORK (Check) ; NEW WELL N/ DEEPEN /% RECONDITION /_/ DESTRUCTION /_ � <br /> PUMP INSTALLATION <br /> _ / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEXRST- SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /0pOTHER <br /> PROPERTYiLINE - PRIVATE DOMESTIC WELL --Afl PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ;.1 Drilled Dia, of Wei l Casing \n t <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation it. Gravel Pack Depth of Grout Sea- <br /> '-Cathodic Protection I Rotary Type of Grout �4 _} <br /> Disposal (I Other Other Information <br /> Geophysics] Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type ofIPump H.P. q <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - k <br /> I hereby agree to comply withall 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 �1 <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 thewell in use.... The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE 94I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY E <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 92 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION P4AJF, 1j:I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - a--1 <br /> E H 1426 Rev. � l-74 . <br /> b/77 _ 2M <br />