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} ' SAN J6AQ13IN LOCAL .HEALTH DISTRICT <br /> f FOFOFFICE USE: 1601 E. Hazelton Ave. ,V Stockton, Calif. <br /> r . <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR FTJMF PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 16 hereby-made to the San Joaquin Local Health District ;for.-a,,permit:•to. construct <br /> and/or install the work herein described, "This appYicatio" n is.'.made_ in ,co mpliance with San-Joaqui <br /> County Ordinance' -No. 1862 and the Rules and Regulations of­the.,.San-:Joag4iq Local..,Health District, <br /> JOB ADDRESS/LOCATION U '/ ( ,. .CEHSU.S TRACT r <br /> F <br /> 8 Name = <br /> h <br /> Owner' <br /> ` . AVA` `y /�? - Phone <br /> ! ,Address /(! ,� 'City <br /> Contractor's .Name <br /> t k ` <br /> License # /3 Phone -/0 <br /> 4 TYPE OF WORK (Check): _ <br /> NEW WELL �j� DEEPEN '/� RECONDITION I_I� DESTRUCTION /7. <br /> _ d <br /> 4 PUMP 'INSTAL TION / / PUMP RE /7 PUMP REPLACEMENT /7 <br /> i - <br /> Other- 7 <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 /> Indus tr'ial <br /> PECIFICATIONSIndustrial Cable Tool Dia. of Well Excavation '• <br /> Domestic/private DrilledDia. of Well ,Casing. :. G <br /> Domestic/public D iven _ r Gauge of Casing <br /> '"Ig <br /> rrigation ravel Pack -Depth of Grout Seal. a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information : <br /> Geophysical. Surface Seal' Installed 'By: <br /> PUMP INSTALLATION: Contractor' <br /> Pump H.P. <br /> i PUMP REPLACEMENT: / / State Work Done. <br /> PUMP +REPAIR: // State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> „•. � � '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, IIwill 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�ROUT -INSPECTION <br /> PRIOR TO GR TING ANDO& FINAL INS?ECTI4N. t <br /> SIGNED .4 44A 0 C TITLE �.�,�f.— <br /> (DRAW PLOT ON REVERSE SIDE .0, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> ' APPLICATION ACCEPTED BY DATE ' <br /> tADDITIONAL COMMENTS: y /, � ; 4 1Z <br /> PHASE..II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY r DATE INSPECTION $Y. ._ , -r DATE <br /> 1426` .. ., � <br /> E H Rev. 1-74' !rl75 2M <br />