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SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> F08fOFFICE USE: <br /> 1602 E. Hazelton Ave: , �Stocktons Calif. di <br /> Telephone:. , {'209) 4.66,4781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r. <br /> THIS PERMIT :EXPIRES 1 YEAR TROM::,DATH-:;ISSUEj) Date'-Issued, <br /> A ation is here ` made to the San`Jon uin Loeal Health District. for •a eramit trs , j <br /> p p <br /> pplic y q construct <br /> and/or install the work herein descrihpd,. ;: This ;applica+t4Lpn-iis�� : in:�compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regul.ations' of+�the�. San Joaquin Local Health District. <br /> 4 _ <br /> z 02.5 ��/� <br /> JOB ADDRESS/LOCATION �" w CENSUS•:TRACT <br /> 0. <br /> Owner°a Name �,pjd y:. �, ul Phone 5?3 J/- <br /> e2S . <br /> Addy - <br /> ess -"City <br /> '�'� <br /> Contractor's Name License # -4,0ij7g Phone S 3 k-7j, L1 <br /> TYKE OF WORK (Check),*- '� DEEPEN_'/-7 RECONDITION /_7 DkSTRUCTION: =4' <br /> PUMP rINSTALLATION- <br /> ST LATION_ PUMP REPAIR /77 PUMP .REPLACEMENT 17the � <br /> A-0— 44AZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY.. ,' <br /> SEWAGE DISPOSAL FIELDS 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 Wel-1 Excavation <br /> J X Domestic/private Drilled Dia. of Well Casing 40 "1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout= Seal -�-- _ <br /> Cathodic Protection Rotary Type of,-Grout t <br /> Disposal Other : . i Other Infor natlon . <br /> Geophysical 'Surface Seal Installed BY: <br /> PUMP INSTALLATION: <br /> Contractor <br /> yp-e of Pu-;.mp r r H.P. 1 <br /> A. <br /> T �� � � <br /> t Sir F d } •. -.. ... <br /> PUMP REPLACEMENT: / :S;tate Work�Done <br /> / # <br /> n <br /> ,,,., : -L/-7 State .W 1Fc. A't } <br /> PUMP, REPAIR ork Done � ,7. , .. .. .. .. ,. . <br /> t ► +. d f <br /> 3, „ES,TRUCTION OF WELL: Well DiameterApproximate 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 pert�'aning;�to or regulating well construction. - Within FIFTEEN DAYS <br /> after completion of my work.on a4new well-,,.,. will furnish the. San!Joaquin..Local Health District a <br /> WELL DRILLERS REPORT of the well aitd notifthem1before putting..the..weli in use.. The above <br /> information is true to the best of my.knowl.ed`ge and belief. ` I .WILL CALL FOR 'A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ) TITLE, <br /> -(DRAW PLOT PLAN ON REVERSEi'SIDE <br /> ,FOR°DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7c� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA UIXNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY,/- <br /> DATE <br /> /fa'-c3C�"7S� <br /> �. . E H 1426 Rev. 1-74 1-74 2M <br />