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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> U OFFICE USE: ii 1601 E. Hazelton Ave. , <br /> Stockton Calif. y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��13 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued I�--7-"7 l <br /> : (Complete In Triplicate), permit to construct , <br /> Application is hereby made �itdescribed.-ThisoapplicationDismade in <br /> n Joaquin cal Health �rict rco compliance with San Joaquin. <br /> and/or install the workihern <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Heilth District. <br /> - Lcl CENSUS T-.RAFT-�; <br /> JOB ADDRESS/LOCATION fAl fit �ruc�tm►"ti .. <br />'t Phone <br /> Owner's Name Et c o r a 7/7 <br /> City <br /> Address <br /> 4 License Id <br /> _ Phone <br /> r <br /> Contractor's Name Ir/ /f<h eD v <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> i Other / { T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD 41 µ:CESSP00L/SEEPAGE FIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE �� <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool `­ —Dia-6f Well Excavation <br /> Drilled Dia, of Well Casing <br /> Domestic/public <br /> ' <br /> Domestic/private-,: Driven Gauge of Casing <br /> -' <br /> �- Grave3.Pack-y-.° -'--Depth-�-of-Grout-Seal----F -� <br /> Irrigation p` <br /> Type of Grout <br /> Cathodic Protection Rotary <br /> Disposal Other Other Information <br /> [ Geophysical Surface Seal Installed B <br /> RUMP INSTALLATION: Contractor + <br /> Type of Pump <br /> State Work Done Lwveni NI <br /> PUMP REPLACEMENT:: .: {d-I � <br /> d <br /> � PU PAIR: / / State Work Done <br /> DES-TRUCTION 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 Heal.t-h�DistrLet <br /> ° and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my woxk on a new well, I will furnish the San Joaqui' ocal Health District ; <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,ihLL-'CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED �,yy ERSETSIDEI� =_ - <br /> (DRAW PLOT"PLAN ON REV <br /> FOR DEPARTMENT USE ONLY <br /> t `n <br /> ( PHASE I �M \1�, DATE <br /> APPLICATION ACCEPTE� :BY �\��v�`v�'"`�" <br /> ADDITIONAL COMMENTS: . PHASE III/FINAL INSPECTION <br /> PHASE II ROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> y <br /> s F H 1426 Rev. • 1-74 <br />