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AAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL <br /> OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> TP-lc? r1 <br /> phone: (209) 466--6781. <br /> 4 �AIID' OR,WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> S T EXPIRES 1 YEAR FROM DATE ISSUED Dat ssued +''�'° <br /> (Complete In Triplicate) , <br /> Application is hereby made to the a�t ked. <br /> Local Health District for a perm t to construct <br /> and/or install the wor reYl "fed. This application is made in compliance with San Joaquin <br /> County Ordinance No� E�� es and Regulations of t e Joaqui H th District. <br /> <:no � y CENSUS TRACT <br /> JOB ADDRESS/LOCATION RAI/ •—� �j/' <br /> Owner <br /> /V/ ��� <br /> 's Name ��1 �- �.� e Phone J d 69of <br /> .� <br /> r� <br /> Address / d `-� �"- .�/j'�}� T City <br /> Contractor's Name <br /> �7 ?a"P-5 License ,� )374hone <br /> 5", <br /> 'a <br /> TYPE OF WORK (Check) : NEW WELL /E DEEPEN /_T RECONDITION /� DESTRUCTION F7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT 1�7 <br /> Other, 1 / <br /> r <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Gauge Driven Gauge of Casing / ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �'_ Rotary Type of Grout <br /> Disposal Other a___� -- Other Information <br /> Geophysical Surface Seal Installed BY: <br /> urs ' <br /> P INSTALLATION: Contractor H:P. <br /> Type of Pump - - <br /> _ r <br /> PUMP REPLACEMENT: / / State Work Done <br /> x Approximate Depth <br /> DESTRUCTION `OF WELL: Well Diameter <br /> Describe Material-and Procedure ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rtainin to or regulating well'constri►ction. Within FIFTEEN DAYS: <br /> and the State of California <br /> peg <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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE r � , <br /> i. !11D W PLAN"ON RSE SIDE <br /> { F EPARTNO T USE ONLY > <br /> PHASE I <br /> DATE <br /> APPLICATIONACC <br /> /LL SNA�6 <br /> ADDITIONAL CON MTS: <br /> PHASE II GROUT INSPECTION PHASE FI INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE - e—- <br /> F '/ij (S") ; -zj <br /> I V , V76 ? 4 <br /> E H 1426 Rev. 1. 74 0 tr o�ri�., Cen.�,,Q 1 �'�. b'vvq- <br />