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,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. Stockton,t ckton, Calif. <br /> Telephone : (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -JcZoS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedp <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 oC the San .7oaquin Local Health District. <br /> h <br /> JOS ADDRESS/LOCATION --c2 L 7 r jIJ,CENSUS TRACT <br /> Owner's Name ed fuo 14 Phone <br /> k Address _g City <br /> I ' <br /> Contractor's Name License ���^-� Phone e- <br /> t TYPE OF WORK (Check) : 1EW WELL /--7�--D'EEPEN,/�PUMP REPAIR PUMP REPLACEMEN <br /> / RECONDITION / DESTRUCTION <br /> INSTALLATION V.- <br /> PUMP INSTA / / T /7 <br />` Other t <br /> 1 L�1 —1 L 9 U c yl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE-'-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i` TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial . II 4\ <br /> .�N �� ;. - _ Cable,Too1 Dia. of Well Excavation <br /> Dome? tic/priDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of_ Casing___ � _�__ Gj <br /> IrFJgationTs—q -� - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Gxout f <br /> i Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. ° 3 <br /> PUMP REPLACEMENT-:-, s ` <br /> _ / / State �.Wor.k Don_"e��, :S �,6 � <br /> PUMP .REPAIR:+ <br /> /, / State Work Done +� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> V 3 <br /> I hereby agree to comply with all laws and regulations of they San, Joaquin Local Health District <br /> and the State. of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> .after compleion of my work on a new well, I will furnish then San'Joaquin Local Health District a 's <br /> WELL DRILLERS REPORT of 'the -well and notify them before puttiagfthe well in use. The above <br /> information is true to the best of my knowledge and belief. Z ALL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FI I SPECTION. ' 'k;SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY \ <br /> PHASE I <br /> APPLICATION ACCEPTED BY e DATE 3d rI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FIN INSPECTION j <br /> INSPECTION BY !! DATE INSPECTION BY ATEj ; <br /> 16 E_H -1426_ Rev. . 1-.74 ' <br /> y 1 �•- 64 7 1 2M ! <br />