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10- �/ ��`SAN JOAQUIN LOCAL HEALTH DISTRICT 5� 4 <br /> [TOE"OFFICE US : 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !_._[_Q�J <br /> (Complete In Triplicate) g <br /> Application is $ereby made to the San Joaquin Local Health District for a permit to construct' <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 CENSUS JRACT ,�(�v <br /> Owner's Name 1'.)S ��� u \4, _. Phone <br /> Address City <br /> 4 <br /> Contractor's Name License Phone77, <br /> -d3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 �r <br /> PUMP INSTALLATION /1.J�PUMP REPAIR/ / PUMP REPLACEMENT +V <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK C= -t SEWER LINES _fit PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD 5�_A CESSPOOL/SEEPAGE PIT -- OTHER --- <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL --- <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i---'Industrial Cable Tool Dia. of Well Excavation <br /> omestic/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 - S- kSS <br /> Geophysical Surface Seal Installed By: <br /> t - <br /> PUMP INSTALLATION: Contractor �p�� t ��� rn� ��,ot�\U �-c�t_ <br /> Type of Pump �i�\1`�1� �� H.P. <br /> PUMP REPLACEMENT; / / State Work bone <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 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 /> info tion is true to the b st of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROUTING AND ECT N. <br /> SIGNED a TITLE '-�:[� ��1. <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> P Sl GR UT INSPECTI Nn, PHA /FIN INSPECTIO <br /> INSPECTION BY DATE Q INSPECTION BY AATEQ/ <br /> f <br /> r 1 177 " 2M <br /> E H 1426 Rev. 1-74 �� ��. <br /> L <br />