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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOF OFFICE 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 1`YEAR FROM DATE ISSUED Date Issued a-ate <br /> (Complete Ia 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules.and Regula" s of the San Joaquin Local Rea <br /> ltb District. <br /> JOB ADDRESS/LOCATION A_4r CENSUS TRACT- <br /> Owner's Name eki VL4 N e u Phone , - <br /> Address S f( 5 - ?" �5� City <br /> Contractor's Name &1N . .4 f License Phoma <br />' TYPE OF WORE (Check):` NEW WELL DEEPEN /-T RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION / /—PUMP REPAIR-/ / PUMP REPLACE �] . <br /> Other %/ <br /> I T <br /> DISTANCE TO NEAREST: SEPTIC TANSLILSEWER LINES J00 PIT PRIVY p ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE " PRIVATE DOMESTIC-WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Iudust-rial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing \ <br /> Domestic/public Driven FN Gauge of Casing i <br /> Irrigation Dep_rb O;LGrout�Seal;:� _ <br /> Cathodic Protection �L Rotary :. Type of Grout <br /> -Disposal Other ` <br /> Other Information� <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � # <br /> -o <br /> Type of Pump R.P. <br /> PUMP REPLA <br /> CSM$NT: State Work Done _ <br /> r <br /> . I <br /> PUMP'REPAIR: .- /��"State Wofkw'Done` '�"' "'.. "� Y .a <br /> DES- <br /> TRUCTION OF WELL: Well Diamete f <br /> Approximate Depth <br /> Describe Material and Procedure i <br /> I\hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSP ION <br /> PRIOR TO GROUT AND A FINAL INSPECTION. y <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE 2)-4- <br /> 1 <br /> ADDITIONAL COMMENTS: GY <br /> P II INSPECTI N PWIA IIVYINALINSPECTI N <br /> INSPECTION B DATE INSPECTION BY DATE <br /> L3_ 177 <br /> 41 <br /> E H 1426 Rev. 1-74`C�1P /�j] =f / �O « . _ �� 1 f j7. 2Ti <br />