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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FR '6 F'xCE USE: — 1601 E. Hazelton Ave. , Stockton, Calif. M oovi L 7o OGt�N <br /> Telephone : (209) 466-6781 7 7 T r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I� THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> �� (Complete In Triplicate) <br /> Application is he j 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 /fa 90 7 P bre �- ESG�} God CENSUS T C <br /> �3e-�S� <br /> Owner's Name tAtk e I C S-T-0 nl r 8 3 9 309 cc Pho <br /> Address 1 l G, City 5S7�.ConE <br /> Contractor's Name License # Rhone <br /> f ^� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / f <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 /> IIt Domestic/private Drilled Dia. of' Well Casing <br /> Domestic \> <br /> /public Driven Gauge of Casing � <br /> Irrigation , Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor AIR- <br /> Type <br /> I2Type of Pump u � (r ..__... ...._.._ H.P, —T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameters `- Approximate Depth <br /> Describe Material and Procedure ; <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 /> 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 my knowledge and belief..- I!ILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG 4MD A INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I II , <br /> APPLICATION ACCEPTED BY W DATE ��_. 7 7 <br /> ADDITIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE III/PINAL III/PININSPEQTION <br /> INSPECTION BY DATE INSPECTION BY `_ � DATE 1-769 <br /> - j�� S�►^� ��. �� � Hca <br /> 2M <br /> E H 1426 Rev 1-74 ,. ., .. r, r. Me .t �917f ,/,� <br />