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��. SAN JOAQUIN LOCAL'HEALTH DISTRICT -- - <br /> ` .FORfOFFICE USE: 1601 E. Hazelton Ave:-,`.Stockton, Calif. <br /> . Telephone: (209) 466-6:781 <br /> APPLICATION FOR WELL CONSTRUCTION OR yPUMP PERMIT Permit No. ?a) <br /> THIS PERMIT EXPIRES 1 YEAR, FROM°DATE ISSUED Date Issued 1-_2f-.Zf <br /> ° d- (Complete ,In Triplicate) <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 :Wade in compliance with San Joaquin <br /> County Ordinance No..1862 and the Rules and—Regulations.— of -the San -Joaquin Local Health District. <br /> JOB ADDRESSS/LO.CATION. CENSUS TRACT <br /> Owner's Name Phone - p <br /> Address <br /> City e <br /> Contractor!s Name AAX9 a eli t�1 -►1 1 JVD License VY2Phone JSP. 191 <br /> TYPE OF WORK (Check 9.WELL /PT_"DEEPEN /7 RECONDITION /_7 DESTRUCTION / <br /> PUMP 'INSTALLATION /% PUMP REPAIR / _PUMP REPLACEMENT /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES /Oft PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- — PIT OTHER p�# <br /> PROPERTY LINE <br /> � -- PRIVATE •DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OWELL CONSTRUCTION SPECIFICATIONS <br />(MIndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public _ Driven 'r"Gauge�of Casing . . 11A <br /> Irrigation- Gravel Pack Depth of Grout Seal -5-0,41 - - - <br /> Cathodic.Protection Rotary Type of Grout 4Le i( �c��1 A, <br /> Disposal Other Other Information . <br /> Geophysical. Surf <br /> , J �"`� - <br /> _. _ ace Seal-Installed-By: lilelo <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. _ ^ <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP 'REPAIR: <br /> E&TRUCTION OF WELL: Well Diameter- 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 TIFTEEN'DAYS <br /> after completion of my work on a new well, I will furnish .the .Saxe Joaquin Local Health District a � <br /> WELL DRILLERS REPORT of the well and notify them befoA_ putting the..well!'in.use:. The above <br /> information is true to the-best-of my- knowledge and belief. I WILL CALL FOR'A 'GROUT INSPECTION <br /> PRIOR TO GROUTIN AND A FINAL, SPECTION. <br /> SIGNED TITLE; , <br /> . (DRAW PLOT PLAN ON REVERSE .S IDLE) <br /> Z <br /> PHASE x FOR DEPARTMENT USE-ONLY i. <br /> APPLIC <br /> ACCEPTED BY DATE �' / T/7 <br /> ADDITIONAL COMMENTS: ��— <br /> PHASE TI OUT INSPECTI N PHASE III FIN INSPECTION <br /> INSPECTION BY- DATE " - INSPECTION BYDATE 1-2-- 61 <br /> E H 1426 Rev. 1-74 1-74 2M <br />