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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: -1601 E. Hazelton Ave. , Stockton, Calif. <br /> M Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na _- <br /> THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED Date Issued <br /> ► 4 <br /> {Complete In Triplicate) <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 /> JOB ADDRESS/LOCATION c2.1 SUP LjC1Uth <br /> dnf t- CENSUS TRACT <br /> Owner's Namenn <br /> Phone 3� 3L4 36 <br /> Address �0C u ' <br /> City <br /> f Contractor's Name <br /> icense Phone d <br /> t <br /> TYPE OF WORK (Check).: `NEW WELL _ ; DEEP/-Z µ`" i v = <br /> -..� _/ '- ECONDITION DESTRUCTION /_7 <br /> /_/ <br /> PUMP INSTALLATION PUMP• REPAIR / / PUMP REPLACEMENT f /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ,#- SEWER LINES `. PIT PRIVY <br /> SEWAGE DISPOSAL FIELDyv -+- CESSPOOL/SEEPAGE PIT OTHER o <br /> PROPERfiY LINE - PRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL \} <br /> INTENDED USE TYPE OF 'WELL CONSTRUCTION SPECIFICATIONS G( <br /> Industrial # Cable Tool Dia. of <br /> Well Excavation <br /> _ Domestic/private Drilled �. <br /> Domestic Dia, of Well Casing S <br /> /public Driven Gauge of Casing 1 <br /> r<aveq.-ack—;r----Depth--:,of-Grout-Seal. v.Q! <br /> Cathodic--Protection G X Rotary Type ,of'Grout � P <br /> Disposal --I Other -5 Other Inf �ormation'" <br /> = Geophysical <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump <br /> P. <br /> PUMP REPLACEMENT: . <br /> / /`,G' State Work Dane <br /> PUMP_:REPAIR:. S.tate_Work.:Done,-_.:r_ i <br /> r ' 6 <br /> DESTRUCTION OF WELL: Well Diameter <br /> .Describe Material and Procedure Approximate Depth <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 FOR A GROUT INSPECTION <br /> PRIG 0 GROUTING N MRPECTION. A� <br /> SIGNED 9 TITLE <br /> DRAW..PI� <br /> T PLAN 'ON RE ERSE SIDE) <br /> PHASE I <br /> FOR DEP•. USE ONLY <br /> APPLICATION-ACCEPTED,.-B <br /> ADDITIONAL COMMENTS: - - - - <br /> DATE _,S Z--?,) <br /> P I ROU INSPECTIO P TII IN INSPECTIO <br /> INSPECTION BY DATE , — + INSPECTION BDATE <br /> p <br /> E H 1.426 ' <br />_ --- Rev. 1-74 / � 3/76 2M <br />