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l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LORrOFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. , <br /> 7a. Telephone: (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-8'94�w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / �7- ' <br /> (Complete In Triplicate) <br />� p <br /> Application is hereby 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 /> `` jj q <br /> JOB ADDRESS/LOCATION .�.]''f C' AJ CENSUS TRACT <br /> Owner°s Name !� • Q A Phone <br /> Address. <br /> City <br /> Contractor's Name RC4,n W � License #,Ae17PV Phone $ F <br /> TYPE OF WORK (Check): NEW WELL -H DEEPEN -/-7 -RECONDITION /7 DESTRUCTION /_7 v <br /> PUMP INSTALLATION /, PUMP REPAIR./-7—pump REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS _FIELD CESSPOOL/SEEPAGE PIT p o OTHER <br /> PROPERTY LINEA PRIVATE DOMESTIC WELL ..W.'PUBLIC DOMESTIC WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation J i7 j <br /> Domestic/private Drilled Dia. of Well Casing ' #1r• <br /> Domestic <br /> /pub �.� _�.:�. ..- Driven- Gauge-of <br /> �__.__... <br /> Irrigation Gravel Pack Depth o€ Grout Seal. ' i <br /> Cathodic Protection Rotary Type of GroutCc Lp� <br /> Tr ,,,._� <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By _.� <br /> PUMP INSTALLATION: Contractor L <br /> Type of Pump a AS H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> E_& RUCTION 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 /> k 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 /> informationtr e. to the-best of knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GRO N AND A FINAL INSPFjtTXbN. <br /> SIGNED TITLES .- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY G <br /> PHASE I <br /> APPLICATION ACCEPTED BY : ,� DATE <br /> ADDITIONAL COMMENTS:SE �.� ' e ./ 04 <br /> P II ROU INS ECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE 3 ' INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M r <br /> S <br />