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SLOT �14R1 11l)CdLO� C�1, <br /> -` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 3 <br /> FOR:OFFICE USE "; 1601 E. Hazelton Ave., Stockton, Calif. � Y <br /> Telephone: (209) 466-6781 `T <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �j•g 9�&I <br /> 776 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lam` __,, r <br /> 7 <br /> (Complete In 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 Joaqui <br /> County Ordinance leo. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION nVe1,4. GGA `tlC7* *4(—; (CENSUS TRACT <br /> Owner's Name 17�. 1 �= Phoned <br />,,Dress City /C"i 'd Al <br /> ... <br />=VCc} tractor's Name ' . , _" _?e 2License # 3/,2/)Phone / <br /> TYPE OF WORK (Check): NEW WELL.'/ DEEPEN -/-7 RECONDITION Lf DESTRUCTION f7 <br /> PUMP INSTALLATION f� PUMP REPAIR"/_7 PUMP REPLACEMENT <br /> Other /� — <br /> DISTANCE TO NEAREST: SEPTIC TANK IonSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I(J�pj 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 Cesin c; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A�c& .Q " <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: . C/ State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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, I will furnish the San Joaquin Local Health District a <br /> WELL DRI, REPORT of the well and notify them before putting.the..well in use.... The abgve <br /> I.inform(tion s true to the eat of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR rT0 G I G 1' INSPECTIOX. <br /> IGNE TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMtT USE ONLY <br /> PHASE T J' -----•-- <br /> AP ION ACCE V44 N Jr DATE <br /> ADDITIONAL COMMENTS: <br /> PII OUT INSPECT( PNMII INSPECT( <br /> INSPECTION BY DATE 6 INSPECTION BY DATE <br /> G' S <br /> E H 1426 Rev. 1-74 &41-/049 / <br />