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�: x, <br /> =' Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH bFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Cali . <br /> Telephone :p (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No. zz� <br /> t <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . /y-7� <br /> Application is hereby made t (Complete In Triplicate) I .: <br /> o 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.�j18 2�an the Rule s^ gulations of the San Joaquin Local ..Health District. <br /> JOB ADD �T�//�I� ✓� �C�. <br /> KESS/LDCATION :fh O-''=� on Wes-t- <br /> 11 Lr T - jUjQ I d CENSUS TRACT <br /> Owner's Name <br /> Phone f <br /> Address r,S O ,/ 3 5 - <br /> CityL <br /> C'ontractor's Name fr' LicensePhone <br /> 3 SS��11 <br /> a; <br /> TYPE OF WORK (Check) ;= NEW WELL DEEPEN /_% RECONDITION /_% DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMPREPA-IR '1_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY �— <br /> SEWAGE DISPOSAL _QQFIELDr �-- CESSPOOI,/SEIaPAGE PTT OTHER <br /> E _ -f PROPERTY _LINE PRIVATE _DOMESTI-C WELL PUBLIC DOMESTIt <br /> INTENDED USE TYPE OF WELL ' _ C WELL <br /> Industrial � ,'CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. , Well Excavation <br /> -Domestic/private �1 Drilled Dia--4of Well Casing <br />'-.�___�,.Domestic/public - I' Drive.ri� �.�w .. ,.. <br /> Gauge of Casing w - <br /> Irrigation Gravel Pack De { <br /> Cathodic Protection . Rotor Rth of Grout Seal C' <br /> Disposal = y Tape of Grout <br /> Other Other Information <br /> Geophysical -;-tk <br /> r <br /> Suface Seal Installed Bmp <br /> PUMP INSTALLATION: <br /> PUMP REPLACEMENT: /. / / State Work Don S <br /> PUMP .REPAIR: 'ey V � <br /> S ! <br /> tate Work Done <br /> DESTRUCTION OF WE 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 regglati.ng 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 />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -' <br /> S LajDrj_M Ch ). TITLE <br /> (DRAW OT LAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' <br /> kDDITIONAL COMMENTS: DATE 9 <br /> PHASE II GROUT -INSPECTION ___PHA7SE__ ./FIN INSPECTION � <br /> INSPECTION BY DATE INSPECTION BY (y <br /> X2917 Gt/L/�,/ r /l0 REGoRD DrT DATE f <br /> E .H-1425 Rev. . 1-74 <br />