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r� _Q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO �OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. <br /> THIS+PERMIT EXPIRES 1 YEAR 'FAOM DATE ISSUED Date Issued <br /> ;.� (Complete. In. Triplicate) ( Sj- f,�p O <br /> Application is hereby made tolthe 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 /> CoMOrdinance No. 1862 and�the`Rules and Regulations of the San �Joaquin Local Health District.. <br /> JOB M'S'S/LOCATION Y DS�' �S� ! ENSUE TRACT <br /> Owner's Name I. wIe Phone ! <br /> Address /� �?dl� City' 5� ,101�9 <br /> Contractor's NameAA),1D,8.'y- A4L?"K1f1ALicense #Zb&Z&hone 4 <br /> TYPE .OF...WORK-(Check)-:• -NEW-WELL- / DEEP RECONDITION'-/7' :, .DESTRUCTION`%f'� <br /> PUMP INET TION / /. '_ UMP REPAIRS/� PUMP.REPLACEMENT <br /> Other k . . <br /> DISTANCE TO NEAREST: , SEPTIC TANK Y SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> [ PROPERTY LINE •- PRIVATE'DOMESTIC WELL" PUBLIC DOMESTIC WELL �� E <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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gr'a3e1 Pack Depth of Grout Seal --�- <br /> Cathodic Protection °. Rtltary• `. fit Type-' f Grout <br /> Disposal. Other Other Information <br /> Geophysical , , '+ Surface Seal -Installed B • <br /> PUMP INSTALLATION: Contractor a h fe <br /> Type. of Pump ., ,.., �_ H.P. ! <br /> PUMP REPLACEMENT / / State Work Done a r' <br /> Y <br /> PUMP .REPAIR: # / / State Work Done <br /> I}ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <.t <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 puttingthe .well in.use.... .The above - <br /> information is true to the-best-of. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. I <br /> SIGNED : <br /> (D T 13LAN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i I <br /> APPLICATION ACCEPTED BY DATE ' / / 177 { <br /> ADDITIONAL COMMENTI F <br /> PHASE-11 GROUT -INSPECTION_ _ . .,,'_. _�._. _ __-_?RASE 1II FINAL�INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY 14,,j .DATE -7 -72 <br /> E H` 1426 Rev. 1-74 h/75 2M <br />