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Ig <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT �1�5 <br /> �'OF.OFFICE USE. ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> / Telephone : (209) 466-6781 <br /> f. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No" � y` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ./4)0]7 <br /> A (Complete In Triplicate) , <br /> Application is Aereb_y...�!!"'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/LOCATIONLld AU CENSUS TRACT <br /> Owner's Name AA Iri <br /> I� A Phone - <br /> AddressLl q �' <br /> CitY.' 6L <br /> I� <br /> Contractor's Name License ���� Phone ' - <br /> rr <br /> TYPE OF WORK .(Check) : NEW_WELL.X-„DEEPEN _/ / RECOND.ITION %7 sDESTRUCTION <br /> t - -- PUMP-hNSTALIATION / / - 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 - PRIVATE DOMESTIC WELL { PUBLIC DOMESTIC WELL . <br /> n k <br /> INTENDED USE ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS . 1,1� <br /> 'Industrial Cable Tool Dia, of Well Excavation <br /> Domesti% c/private, F( Drilled Dia, of Well-Casing� <br /> Domestic/public IM Driven Gauge of Casing - y ' <br /> t-IrrigationIM Gravel Pack Depth of Grout Seal- UV <br /> — Cathodic.Protection IM Rotary .< Type of .Grout <br /> `Disposal IM Other s Other Info mr ation „� ,d <br /> Geophysical Surface Seal Installed B : i tl <br /> PUMP INSTALLATION: Contractor ! 1 <br /> " Type of Pump H.P. <br /> I. II� � � <br /> PUMP REPLACEMENT: - / / pState Work Done , <br />,PUMP-.REPAIR.:— �S•ta.te;Wo.r-k-_Done�. .� n ,� <br /> DESTRUCTION OF WELL: Well Diameter Approxi ate Depth <br /> a Describe Material and.,Procedure <br /> h Wef 6t6p y .C�s►3 <br /> ereb a r om 1 it all laws a regulations of he 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 andj1otify them before putting the -well in -use. The above <br /> information is true to t be o knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ING D A N ON. <br /> SIGNEDTITLE <br /> �M (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �dIlzh7l <br /> ADDITIONAL COMMENTS: M <br /> PHASE I GROUT INSPECTION PHASE IildFINAL.,INSPECTION <br /> INSPECTION BY ZV DATE / '27 INSPECTION BY ATE 7� <br /> E H .1426 Rev. 1-74 !�. 1177 2M T` # <br />