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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW O"ICE USB: 1601 Be Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERHIT EILPIRES 1 YEAR MLOX DATE JIM Dste Issued _7,' <br /> (Complete In TrAiplicate) <br /> Health.Distri t for <br /> Application harsh 'Y made to the San Joaquin Local* c a peroit to construct <br /> and/or install the work herein described. This application is made .in co#pliaaae.with San Joaquin <br /> County Ordinance No. 1862 and the Rules and .Regulations of:the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION ): �,.5 I�Y 1� + c� , •� ` CENSUS TACT <br /> Owner' Nsae '� ! ''. - Pboue - t ' �2 ?6 <br /> Address �,. A-91f � City O" <br /> Contractor's Name "► <br /> ��elt L470 -LAO <br /> License #_j5 Phone elA 2 fr+".a 40 <br />=TYPE OF WORK (Check)t NNW WELL L7 DEEPEN 17 RECONDITION f J DESTRUCTION L7 <br /> PUMP INSTALLATION PUMP REPAIR-/� PUMP REPLACEMENT <br /> Other L7 <br /> DISTME11 TO NEARESTt SEPTIC TANK SEWER LINES FIT PRIVY <br />` SEWAGE DISPOS BIER CESSPOOL/SEEPAGE PY R OTHER <br /> M L - P STI PUB I S I <br /> IN'PENDE `USE TAPE OP WELL CONSTRUCTION SPECIFICATION$ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Y Depth of Grant Se+sL <br /> Cathodic Protection .Rotary Type of Grout <br /> Disposal Other Other Information <br /> .-geophysical -_Surface _ I <br /> PUMP BTIIl.L ox: Contractor.. <br /> Type of Pump 000 <br /> I <br /> PUMP RRPLkMWWt -staie -Work_.� s. _. <br /> Done <br /> PUMP :REFAI&t.._ <br /> ,/� State Work_Done.: <br /> I Imo, I <br /> QF WBLL Well.-Diameter <br /> DES tUC Imp lam._._. . - ftp juts Depth <br /> Describe Material and Procedure <br />;I hereby agree to comply with all iays aid regulations ofthe San oaq ca ; Health District <br />'and the State of California pertaining to or regulating well"construction.- ft-thin FIFTEEN DAYS , <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br />�= DRILLERS REPORT of the well and notify them before putting.the.-w ell. iu.use.... .The above <br /> Information is true to the•best.of. my..knowledge and belief. , I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO ORDUTM AILD FINAL INSPECTION. <br /> SIGNED TITLE �r . � ` .,.. <br /> RAW PIAT P ON SSS SIDE)"', <br /> IDE ......._......._...... <br /> R PARTMENT USE O y <br /> PHASE I <br /> APP KATION ACCEPTED BY DATE <br /> ADDITIONAL MTB: <br /> PHASE II Gum INSPECTION B 11F1NAL IN8PECTIO11 <br /> INSPECTION BY DATE INSPECTION BY <br /> S R 1426 Rev. 1-74 `' <br />