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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) .466-6781 <br /> M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ILZZ� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued MAY2 , <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 Joaquin <br /> County ,Ordinance No. 1.862 an4 ,the <br /> Rules nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - _ -r <br /> ESUS TRACT <br /> Owner's Name AR4 T Phone <br /> Address .. <br /> City fSe Al-Q <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN$/ / RECONDITION /_7 DESTRUCTION /_ _ <br /> PUMP INSTALLATION/ PUMP REPAIR / / PUMPS REPLACEMENT / / a <br /> Other 9/ OLD 75 ..� Q4� <br /> Ilr DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES PIT PRINY _ <br /> -S-EWAGE''DISPOSA-Lr .--CESSPOOL/SEEPAGE'PIT '"-_." '•`y OTHER Q, <br /> PROPERTY LAVE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS cls: <br /> Industrial Cable Tool Dia, of Well Excavation , <br /> Domestic/private Drilled Dia, of Well Casing. <br /> Domestic/public Driven Gauge of. Casing -S <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed By: ; <br /> PUMP INSTALLATION: Contractor '°7, k~40 f.. <br /> Al I <br /> Type of Pump_. H.P. '_ ._ <br /> PUMP REPLACEMENT: / % State Work :Done <br /> PUMPREPAIR. _.. <br /> : / / , State Work Done <br /> ��\ <br /> OF WFIL: .} e 1 D a <br /> DE5 TRUCTION ter proximate 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 newrwelJ;,Ii_wi1.l 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 GROUT INSPECTION <br /> PRIOR TO GROUTLNG AND A F OVAL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l _; <br /> APPLICATION ACCEPTED <br /> By _ DATE <br /> ADDITIONAL COMMENTS: -- <br /> PHAS&II GROUT- INSPECTION P E .;PVFINAIe INSPECTION p. <br /> INSPECTION BY DATE, _ INSPECTION 'BY DATE <br /> E H..1426 Rev. 1 74' <br />