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/ VV- rvvl <br />t,, JOAQUIN LOCAL. HEALTH DISTRICT, <br />FOF 0 FICE USE: 1601 E. Hazelton Ave., Stockton, Calif. 6 3 <br />Telephone: (209) 466-678 <br />APPLICATION FOR WELL CONSTRUCTION 0 <br />kko#1 <br />IT Permit No.THIS PERMIT EXPIRES 1 YEAR FROM ate Issued 1-aG(Complete In Triplicate) <br />Application s hereby made to the San Joaquin Local Health Dist to construct <br />and/or install the work herein described. This application is made ia e with San Joaquii <br />County Ordinance No. 1862 and the Rules and Regulations of the San JoHealth District. <br />JOB ADDRESS 3i A9 % CENSUS <br />Owner's Name L �b % C D h' f Phone <br />Address <br />Contractor's Name IM D DYr19ii.a e <br />City <br />TRACT <br />License 411hone <br />TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /—% <br />PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT /_7 <br />Other / / <br />"OLA UL ru NEAREST: <br />SEPTIC TANK��- SEWER LINES SPIT PRIVY <br />SEWAGE DISPOSAA F ELD <br />CESSPOOL/SEEPAGE PIT4-GTHER ^� <br />PROPERTY LINB IVATE DOMESTIC WEL.II_'r_t PUBLIC DOMESTIC WELL �- - <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Industrial <br />Cable Tool <br />Dia. of Well Excavation Z �� <br />)( Domestic/private <br />T-Domestic/public <br />Drilled <br />Dia. of Well Casing S/y <br />Driven <br />Gauge of Casing <br />Irrigation <br />Gravel Pack <br />Depth of -Grout Seal r <br />Cathodic Protection Rotary <br />Type of Grout 00 <br />Disposal <br />_ <br />Other <br />Other Information <br />Geophysical <br />c,af� e Q-1 <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT <br />PUMP REPAIR: <br />Contractor _ <br />Type of Pump <br />State Work Done <br />State Work Done <br />DESTRUCTION OF WELL: Well Diameter <br />Describe Mater <br />Procedure <br />H. P. <br />Dept <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 />information is true to the best of my knowledge and belief. I WILL CALL TFOR A GROUT INSPECTION <br />PRI9R 1'O GROUTING AND A FINAL INSPECrIOU4 <br />�'//J�2�L..� TITLE <br />SIGNED <br />PHASE I �D <br />APPLICATION ACCEPTED BY _ o / DATE <br />ADDITIONAL COMMENTS:. / TJ <br />INSPECTION BY DATE .1,0/76 INSPECTION <br />F2 <br />