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bt &-'A'00,40 la_<7 --- - _ . <br /> C/47 Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrrflFFICE USE r 1,601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone; . (209) 466-6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�V_ z Z.� t <br /> THIS. PERMIT -EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> . (Complete. In Triplicate) <br /> A I <br /> pplication 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. .1852 and the Rules.and .Regulations of the San'Joaquin Local Health District. } <br /> 4 5 <br /> JOB ADDRESS/LOCATION ir j (CENSUS TRACT <br /> Owner's Name Y' ,5 Phone M <br /> Address SC City . <br /> Contractor's Nsme A`� <br /> L� r.� License # G9j7��hone 6(X 74X <br /> TYPE OF WOE (Check): NEW WELL /-7 DEEPEN '/'7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION I / PUMP REPAIR 1,LK7 PUN? REPLACEMENT /7 <br /> Other 1% ' <br /> DISTANCE TO NEAREST: : SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER x <br /> •" L <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS X <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/publkai t Driven Gauge of Casing i <br /> k Irrigation ct } Gravel Pack Depth of Grout Seal <br /> s -"Cathodic Pr6te ,lbn Rotary Type of Grout' �. <br /> 'Disposal (Other Other Information <br /> Geophysical `► <br /> .. � Surface Sea! Installed- By:_ <br /> 1� <br /> UMP INSTALLATIOk. Contr�etor V �r�Tvb <br /> }. Type of Pump -t i H.P. <br /> PUMP REPIkEMENT: j_/ 'State Work Done <br /> a.P!M� .REPAIR: State Work Done' Wo k..? WOR •-- sea wo . q_✓_�_- �`_ <br /> ESTRUCHON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a <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 at <br />!--WELL DRILLERS. REPORT of'the well and notify them before puttingthe. well in use.. The above <br />>,. -,information is true to"the.,best-.of my.knowledge and belief. I WILL CALL FORA GROUT INSPECT.ION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> s SIGNED - • r TITLE <br /> w� PLOT PLAN'ON REVERSE SIDE Mme; <br /> OR DEPARTMENT USE` ONLY <br /> PHASE I CE _ <br /> APPLICATION ACCEPTED BY ATE z- <br /> F ADDITIONAL COMMENTS: <br /> " - PHASE II Muo R!SPtCT_10N <br /> ZZZ� AL INSPECTION <br /> INSPECTION BY DATE INSPECTIO DATE c_S= O-7 <br /> E H 1426 Rev. 144 1-74 2M <br />