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_ 4SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION QR PUMP PERMIT Permit No. -36 ,r) <br /> THIS PERMIT EXPIRES 1 YEAR FROM:DATE ISSUED Date Issued <br /> - In. Tri <br /> (Complete pl.ic�te} .. <br /> Application is hereby made t' o the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This-appl.ication is made in compliance with Sari Joaquin", <br />. . County Ordinance No. 1852 and the Rules and lat s of the —San—Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,f �2 CENSUS TRACT <br /> Owner's Name =t:::�44A-cm 121+ ` Phone --3 5/d % <br /> / - . <br /> Address ,7. <br /> Contrictar's Name tq. ` License <br /> TYPE OF WORK (Check):- NEW WELL /DEEPEN -/7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR •/-7 PUMP REPLACEMENT /7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK dl SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY. LTNE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IIIINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `Industrial !' Cable Tool Dia, of Well Excavation /Y -, <br /> Domestic/private, Dr4wrilled Dia. of Well CasingJIV <br /> l Domestic/public tr\,,. % Driven-\ -Gauge;-of Casing __-_ <br /> Irrigation �. Gravel Pack Depth` of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - IN 0.0ther 7 Other Information ' ' <br /> Geophysical Surface Seal­Installed 'B <br /> E <br /> PUMP INSTALLATION: '� Contractor r <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done{ <br /> PUMP °.REPAIR's�" / / State'Work Done'- � _ . -. . . ---�. <br />' DBS;TRUCTION OF WELL: Well. Diameter i Approximate Depth <br /> Describe -Material and Procedure <br />' I ,hereby agree to comply with all lawsland regulations of the San Joaquin,Local Health District <br />; ana.the State of California pertainingito or regulating well"construction\:6�Within FIFTEEN DAYS, - . <br /> ft <br /> aer completion of my work on a new well., I will furnish the San Joaquin'Local Health Districtia. <br />' WELL DRILLERS REPORT of the well and%-no'tify them before putting•.the..well. in .use... The above <br /> information is true. to the•best of- my'. knowledge and belief. I WILL CALIF FOR A ' ROUV INSPECTION <br />;PRIOR TO GROU G - D A IN N ECT N. , <br /> SIGNED TITLE <br /> (DRAW PLOT' PLAN ON REVERST�- IDE `• ' <br /> s _2 � .� :FOR 7E 'ARTMENT USE <br /> ONLY,__ <br />' PHASE_I ---.;sem-.:...• •` •�5�� � ', -��� �_..:,.,—»�•--..�r....-- ------� <br /> APPLICATION ACCEPTED $Y �s ^: a -DATE <br /> A1]DI_TIONAI. COMMENTS: — -- <br /> PHASE II. GROUT INSPECTION.n t� } PHASE FIN INSPECTION <br />' MSPECTION BY -: : DATE _;e µ �CNSPECTION BY DATE <br /> . <br /> " E H 1426 Rev. ,-14 _ L/75 2M <br />