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} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE=USE: ' 1601_ E. Hazelton Ave. , •Stockton, Calif. <br /> _� Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '-V-/3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> L� <br /> In Triplicate)(Complete p ) <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 No. 1862 and the Rules and Regulations-of the San Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION Q Q [p 6A-0 CENSUS TRACT <br /> Owner's Name ��'wr E � S I.�2 _-- Phone a- S <br /> Address _ sd,t D VC) 4 r aAltO� City a <br /> Contractor's Name Alt,t License q_ Phoneg� - �S <br /> z <br /> TYPE OF WORK (Check)h: NEW WELL / DEEPEN / / RECONDITION_./_7 DESTRUCTION /-7 ; <br /> PUMP INSTALLATION / / PUMP REPAIR /�,/ 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 0WAIVATE DOMESTIC WELI6.1! PUBLIC DOMESTIC WELL •� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS " • <br /> Industrial V Cable Tool Dia. of Well Excavation " <br /> Domestic/private ! Drilleda Dia, of Well Casing ' . d Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack s :Depth of Grout Seal <br /> Cathodic Protection Rotary A ;Type of Grout 1 <br /> Disposal Other , f •� <br /> • �Other.�,lnfo.rmation. _.. <br /> Geophysical: •Surfa.ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` - <br /> Type of Pump H.P. <br /> - Y <br />; PUMP REPLACEMENT: / / State Work Done ' <br />� PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth ' a <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 /> lafter 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 th The t of �. y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />.PRIOR OU ING D A F NS ON. _ <br /> ` SIGN DAt TITLE ; <br /> 01 <br /> (DRAW.PLOT PLAN ON REVERSE SIDE) <br /> f FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 , <br /> ADDITIONAL COMMENTS-.' <br /> PHASE II GROUT INSPECTION PHASE I I/FIN , INSPE TION' <br /> INSPECTION BY DATE INSPECTION BY DATE 3�_ '7 <br /> E H 1426 RP17_ I--74 <br />