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91 <br /> j Ze <br /> W S �JOAQUIN'LOCAL ATH.�1 T <br /> FORiOFFI,CE USE: ICT <br /> 1601 E. Hazelton Ave. , Stockton;. Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5_3�_Ie_2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED Date Issued 1R_ .-» <br /> Application is he (Complete In Triplicate) <br /> reby made to the Salt 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. nd the Rules and Regulations:of the San Joaquin Local Health District. <br /> JUB�AIIDRESS OCATIO�N .����'9'�/� �," � . <br /> - 'r' S%/7V'&SUS TRACT <br /> Owner's Name / <br /> Phone <br /> 2LLAddressCity ? <br /> Contractor's Name�729 License phoned <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION El PUMP REPAIR PUMP REPLACEMENT 17 <br /> Other J / — <br /> DTSTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> . $MAGE DISPOSAL FIELD CESSP©OL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' - PUBLIC DOMESTIC WELL <br /> INTENDED i]SE TYPE �F WELL CONSTRUCTION SPECIFICATIO <br /> Industrial <br /> Cable Tool Dia. of Well Ekcavation N$ G� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing a ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Groot' , <br /> Disposal - Other Other Information <br /> Geophysical '�"��- <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> +� Type of Pump3 <br /> _ H.P. <br /> J <br /> PUMP REPLACEMENT: / State Work Done <br /> °PUMP-:REPAIR:" - f "' Stte'WorkDoTgQ _ <br /> hn' <br /> ES;TRUCTION OF WELL: Well Diameter(34 C -�� A <br /> ro imate Depth <br /> Describe Material and Procedure ellllo.._,�_,��� � <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 wrell '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 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. GROUT INSPECTION <br /> SIGNED _ ` <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE "._ . <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSP TION # <br /> INSPECTION BY <br /> PH * AhASE I FINAL INSPECT N <br /> DATE INSPECTION BY DATE <br /> A <br /> E H 1426 Rev. 1-74 t <br /> �' 1-74 2M <br />