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F_ SF i <br /> USAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> OR OFFICE USE: 1601 .E. Hazelton Ave. ,. Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. ; <br /> LLU <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 l7 7,5" <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. 1862 and the Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION 2,9_ Z e CENSUS TRACT i <br /> Owner r s Name _Xs Phone <br /> Address _:._.�� / edge t5 ;�,e .,.. P ' City SZ4CA7;:5A1 <br /> F <br /> Contractor's Name C License._ 4�J 7 Phone <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN -/-7 RECONDITION /7 DESTRUCTION /-7- <br /> PUMP <br /> 7-PUMP INSTALLATION /' / PUMP REPAIR /-7—PUMP REPLACEMENT / <br /> Other 1_7 <br /> DISTANCE TO NEAREST: (SEPTIC TANK SEWER LINES PIT PRIVY 4,} <br /> E r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ---• <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I dustrial Cable Tool Dia. of Well Excavation 0 <br /> Daroe-stic/privat rifled &-�- Dia:of-We`11 Casings �- <br /> k <br /> Dome stic/pubjfc,-""" , ' ; \Driveh r4 Gaugs rof.-Casing; <br /> Irrion Gravel Pack Depth of Grout <br /> Cathodic Protection w� �_Rotary Type of Grout C� X, /'7_ _-r <br /> gati <br /> Disposal Other Other Information <br /> Geophysical ,Surface ,Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . - �' H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Dbne' . <br /> PUMP :REPAIR: /7 State Work Done <br /> RES•TRUCTION OF WELL: Weil Diameter �,.,, . .� �� _ Approximate Depth s <br /> Describe Material and` Procedure , <br /> I hereby agree to comply with all laws and regulatio#is of the San Joaquin Local Health District <br /> and the State of California pertaining,,to or re.gulat.iug well—mastrVEtion. Within FIFTEEN DAYS <br /> after completion of my wo=k on a new wel'1 '%I will furnish the San_J.oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before g ting�th�. well in use.. The above ,. <br /> information is true to the'7- est of. my knowledge and ~b :liQf. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' - <br /> FOR DEPARTMENT USE° ONLY % <br /> PHASE I <br /> APPLICATION ACCEPTED BY < DATE <br /> ADDITIONAL COMMENTS: 17 01 1 <br /> F <br /> PHASE II GROUT IftPECTION <br /> INSPECTION BY DATE INSPECTIONBY DATE /Z� �G <br /> ;t E H. 1426 Rev. 1774 :.r;. ., <br />