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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$�rOFFICE USE; / 1601 •E. Hazelton Ave. ; Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l' YEAR•FROM DATE ISSUED µ Date Issued /7-0� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Disttict. 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. J862 and the Rules and: Regulations of the San Joaquin Local Health District. <br /> �d bra G 1� �. , <br /> JOB ADDRESS/LOCATION ( rc1 CENSUS TRAC7f'` G2 <br /> Owner's Name - qT Phone <br /> Address; , _ .. y <br /> / X94 a <br /> 5 "! f -z <br /> °Contr4ctor's Name }License #jam jl Phone 2.?l i <br /> 'TYPE OF WORK (Check): NEW WELL-& DEEPEN/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /�J®PUNP REPAIR /_7 PUMP REPLACEMENT 17 <br /> Other /7 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK ip SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL , : PUBLIC DOMESTIC WELL \ f <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> amestic/private Drilled Dia. of Well Caving <br /> - mes Aclpubifc4-M -F :-Driven--- Gauge_o€.-Cas#ng -� <br /> s rrigation �G'rsvel Pack Depth of Grout Seal ._ <br /> -.Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other Information t. <br /> Geophysical Surface Seal Installed-Bv;'.•'br.t,�, <br /> PUMP INSTALLATION: Contractor - <br /> " Type of Pump H.P <br /> •PUMP REPLACEMENT:, -�/; /.;�rS tate-sFork_Done <br /> .PUNP :REPAIR: /? State Work Done <br /> BS;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 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-b6s -.-- my.knowledge' and belief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A*INAL INSPECTION:.-�r <br /> SIGNED �- '- ,�L TITLE <br /> 090 PLOT PLAN ON REVERSE SIDETL . <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY:�'. DATE <br />_ ADDITIONAL COM49NTS: i <br /> ``PHMVII S CT \ PHASE I PIN INSPECTIO <br /> INSPECTION BW4Q& DAR \! `"� INSPECTION- BY DATE .;w <br /> E H 1426 Rev. 1-74 .. f <br /> 1-74 2M <br />