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SAN JOAQUIN LOCAL HEALTH. DISTRICT C <br /> FOI! OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> 21 ADPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _/�{7 <br /> A, <br /> 7iiii THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 _&_22 <br /> (Complete In Triplicate) <br /> A lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> PP <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 /> JOBADDRESS/LOCATION Al, <br /> iG► 4*_ CENSUS TRACT <br /> Owner's Name p e �® ` �� Phone <br /> Address. � � City <br /> Contractor's Name I� License gar # llj4 phone G 7 +� P <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /;C/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC- WELL <br /> INTENDED USE P TYPE OF WELL CONSTRUCTION SPECIFICATIONS W, <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 Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor �_. -' H.P. y.� <br /> IType of Pump f <br /> 4. k <br /> PUMP REPLACEMENT: / / State Work Done 0 + <br /> PUMP .REPAIR: %�/ State Work Done a <br /> DES-TRUCTION OF WELL: Well Diameter Approximate. Depth <br /> Describe Material and Procedure <br /> k <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> M and the State of California pertaining to or regulating well --construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District A <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to 'ihe best of my knowledge and belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AN A� FINAL OST. <br /> SIGNED .! TITLE . . <br /> i ffjj ..pl, "p PLAN ON ERSE SIDE <br /> h FOR DEPARTMENT USE ONLY <br /> PHASE I . . % <br /> r APPLICATION ACCEPTED BY DATE f�` <br /> ADDITIONAL COMMENTS: �! <br /> PHASE II 'SINS CTION PHAS III/FINAL INSPECTI N <br /> INSPECTION BY i�: DAT INSPECTION BY DATE <br /> E H 1426 Rev. 1-7G , '''7 ,. ©,� � <br />