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�' 1 -i -et 7713�l� <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT kF r p <br /> EOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. ! <br /> lie <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 <br /> . �'! <br /> `� �� (Complete In Triplicate) ` <br /> Application is tereby 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 /> OB ADDRESS/LOCATION '� CENSUS TRACT ��7' 3�r0-I2 <br /> Owner's Name ,9 ... �� Phone <br /> Address. 4-,?) 2 �J n"ICS �. -- - City .4ct-11an; <br /> Contractor's Name Zli License Phone y <br /> a <br /> TYPE OF WORK (Check) : NEW WELL X1 DEEPEN.;/ ./_,_RECONDIT.ION /-7. ..DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 700 + SEWER LINES PIT PRIVY ;y , <br /> SEWAGE DISPOSAL FIELD -� CESSPOOL/SEEPAGE PIT OTHER -1 <br /> PROPERTY LINE/3 PRIVATE DOMESTIC WELL. l PUBLIC DOMESTIC WELL { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial F _ Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing //, �� _ -:-.1 <br /> Domestic/public Driven s Gauge of Casing-- :4o v� <br /> Irrigation Gravel Pack Depth of Grout Sealql <br /> Cathodic Protection Rotary --Type of Grout _. 0- <br /> �> <br /> Disposal Other Other Information .�--- <br /> Geophysical. ' Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> +, <br /> Type of Pump H.P. y <br /> PUPS REPLACEMENT: /;1: / State Work Done MA AT 'Kr---1'114 o <br /> r. <br /> PUMP `.REPAIR: /11 /�: State Work Done <br /> DESTRUCTION OF WELL " -W&11-Dia"ineter Approximate Depth <br /> ._ . .., . ...___,— Describe Material -and Procedure <br /> EI 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 ofmy 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 t the st f y owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AN A FIN P 010 <br /> SIGNED- ' TITLE aCAI - <br /> l� DRAW .PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />� PHASE <br /> rAPPLICATION_ACCEPTED BY 41 DATE ��,- <br /> ADDITIONAL COMMENTS: Ir <br /> PHASE_II GR'OU INSPECTION PHASE I/FIN INSPECTION <br /> INSPECTION BY dp DATE INSPECTION BY DATE - -'7F <br /> E H'1426 Rev. 1-741 <br />