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.C-1 <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR, ICE USE: 1601 E. -Hazelton,.Ai.Fd,..-,,. Stockton, Calif. <br /> Telephone:. ti..(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS-PERMIT EXPIRES1-YEAR,.,-FROM-.-,-DATE-fl SSUED,f , Date IsAided'. <br /> {Complete In Triplicate),:., <br /> #Pplicition is hereby made to the San Joaquin -Local,.Heal-th,Diattict!:,for,a:-permit t'' <br /> o� cotstruct <br /> and/or install the work herein .described,,.. This.,application,isr =de:,.in'!compliance:.Vith San'Joaquin <br /> Countylrdinance No. 1862 and. the-,Ruies�.an&.Regulationd:of_:Lthe San,.Joaquin-.Local Health-Distric <br /> JOB"ADDR6S/jOCATION <br /> CENSUS.-TRACT 2-Y5-c70-0_3 <br /> �4­ qcn. <br /> Owner's Name Phone e-- 77,1 7 <br /> Address <br /> City <br /> Contractor's Name License.4 jgala -phone 3 57�'2e) <br /> TYPE OF WORK (Check.)." NEW WELL DEEPEN /7 -RECONDITION /7--DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 Pump REPAIR /7-pumpREPLACEMENT- U <br /> Other <br /> —/222aM 11�) <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - -PRIVATE- DOMESTIC -WELL --- - PUBLIC DOMESTIC 'WELL <br /> INTENDED USE i TYPE OF WELL PqNSTRUCTION SPECIFICATIONS. - <br /> Industrial TCable-Tool Dia. of Well Excavation <br /> Domestic/private Drilled- :Dia. -of- Well ,Casing jy il, <br /> Domestic/public -, Driven, _Gauge of Casing. <br /> Zcrm._ <br /> Irrigation Gravel Pack Depthof Grout Seal <br /> Cathodic Pr-otectioti Rotary Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed BY: V,=�t4q_,4 _U2� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMM:," State'woik Don-e" j- <br /> -Work- <br /> ,RE&TRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and r'egdlations of the San Joaquin Local Health District <br /> and the State of California pertaining to or'regulating well cbn.stru I tidn.' Within' FIFTEEN DAYS <br /> after completion of my work on a,new well, I will furnish.Ahe .San Jo=in. Local Health District a <br /> WELL DRILLERS REPORT -of the well and notify,thez� before putting, the. "ll in.use. The above <br /> information is true to thebest of my.-knowledge 'and belief". '-I' WILL CALL' FOR''A 'GAOUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED --+1)44 W_awdJ2 TITLE <br /> V , <br /> (DRAW TLOT .PLAN ON REVERSE SID_E7____a <br /> FOR-DEPARTMENT USE ONLY <br /> PHASEII <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL- COMMENTS:. t <br /> PHASE II ,GROUT INSPECTIONPRA u jy1YINAL INSPECTION <br /> INSPECTION BY DATE INSpg <br /> DATE <br /> Z42 'c_.42 <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />