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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. \. <br /> h Telephone: (209) 466-6781 �� 4/NI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued "(!'`' <br /> (Complete In Triplicate) 1' <br /> f Application is ereby made to the San Joaquin Local Health District for a permit to construct 4. <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 r3 �.. ®���{�' �'`a--� CENSUS TRACT <br /> Owner's Name PAILRY4 Phone � <br /> Address G4,L U City <br /> 0 0y . <br /> License r,. hone. <br /> Contractors Name �. u <br /> I. <br /> 4 %o iwaR -{chemo) N w wE ?DEQ EN = R caRM M <br /> . . <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> other / / .� ; <br /> w 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 TYPE OF WELL CONSTRUCTION'SPECIFI TIONS <br /> Industrial Cable Tool Dia. of Well. Excavation_._� U <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing'— 1-/. _ .r <br /> :: . � Gravel..Pack. Depth of Grout-Seal 7, <br /> t Irrigation va- �-' <br /> Protection Rotary Type of Grout T;,- <br /> Cathodic .-+fcr� <br /> Disposal Other Other Information , ' <br /> ` - Surface Seal Installed By. _ <br /> O e <br /> i Geophysica�:�.: - � }- � -� .y y� �-. <br /> PUMP INSTALLATION: ` Contractor GY <br /> Type of'Pump . " v� l`i?ti 4� r H.T. <br /> s <br /> PUMP REPLACEMENT / / State Work Done <br /> } <br /> PUMP .REPAIR / LState_W_o_rk Done - <br /> . ADepth <br /> DESTRUCTION OF WELL: Well Diameter pp roximate -------�==�- <br /> } Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the-Sari Joaquin Local Health Distxicti <br /> I and the State of California pertaining to or regulating well•construction. Within FIFTERN DATE; <br /> ` after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL REPORT of the well and notify them before putting the -well in use. The above <br /> inform ion true Cn Ke eb s of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIG TD GRO G A NAL VSPECTION <br /> SIGNE �_ TITLE J�fk'2G . V1 <br /> D W. PLAN 'ON UVftSE SIDE ,• "I; <br /> 4 FOR DEPARTMENT USE ONLY 11 <br /> PRASE I <br /> APPLICATION ACCEPTED. BY DATE -_ <br /> ADDITIONAL COMMIS:., <br /> P I GROUT INSPECTION PHA SE I FINAL INSPECTION :. <br /> INSPECTION BY DATE _ 5 12- INSPECTION BY DATE <br /> V7 <br /> F. E H 1426 Rev. 1.74 _ <br /> 3 <br />