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! r ---- SAN !OAQU1N LOCAL HEALTH DISTRICT rR <br /> C : ICO �;. k{nzelton Ave <br /> i " <br /> . , Stockton, Calif. �i: � <br /> Telephone: (209) 466-61$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. },�F' <br /> T=TIS PERMIT EXPIRES I AAR FROM DATE ISSUED Date Issued I� <br /> (C )Iete In <br /> Applichtlon is Aereby made to the San Joaquin Local HealthtDistrict fora permit to construct <br /> and/or install the work herein described. This application is made in Compliance with San Joa <br /> County Ordinance No. 1862 and the Rules a d Regulations o the San Joaquin <br /> 1 N �A Rs: O W N W tion e" A'T- <br /> .oca1 alth Diatrie <br /> JOB ADDHESG/LOCATION <br /> Okrner's Name n <br /> Phone ` <br /> -Address <br /> s{ / 1(1 <br /> . City , <br /> Contractor's Name '—`�"`�' ! 'A <br /> Al� <br /> ' License 1 ' <br /> Phone Sw <br /> TYPE OF WORK (Check): _NEW WELL /? DEEPEN / RECONDITION L7 OBSTRUCTION <br /> FiiAilP INSTALLATIQN PUMP REPAIR /? PUMP REPLACEMENT L-7 A <br /> Other j% « <br /> _ 1 <br /> z DISTANCE <br /> TO NEAREST: SEPTIC TANK SEWER LIN&S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC L1 <br /> ;.. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> " Industrial f <br /> Cable Tool Dia. of Well Excavation <br /> A �- Domestic/private Drilled Dia. of Well Casing ;}� R <br /> Domestic/Public Driven Gauge of Casing .'; <br /> Irrigation Gravel PAck Depth of Grout Seal h <br /> Cathodic Protection Rotary <br /> ? • <br /> a Disporal Type of Grout <br /> Other <br /> —Geophysical �� Other Information <br /> ++ Surface Sea In al ed BY: lg j,z <br /> ` PUMP INSTALLATION; Contractor ` <br /> Type of rump p j <br /> _ H.P. <br /> PUMF REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> /? State Work Done <br /> '! DEw_S,TTPUCTIQN OF ULLL: Well Dizmeter <br /> Describe ]Material and Procedure Approximate Depth + <br /> ......+ � <br /> 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Health fetrict !I S <br /> and the State of California pertaining to or regulating well 'Construction. Within FIFTEEN DTATS I r <br /> after completion of my work on a new well, I will furnish the San Joaquin L.ucal Health District a a` r <br /> WELL DRILLERS RT of the well and notify them before putting the well in use. The above <br /> informs e o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION a + <br /> PRIOR TO A FINAL. INSP! GI'ION. <br /> SIGNED <br /> TITLE <br /> —� � DRAW PLOT PLAN ONR1rV£RSE SID k <br /> h r <br /> PHASE I `FOR DEPAR MINT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE I: GROUT Irv; 'TION } <br /> INSPECTION BY PHASE II FINAL INSPE—CTION -" ^ <br /> ilA: --- INSPECTION By/ PATE <br /> E H 1426 Rev. 1-74 I/77 2N { <br /> R <br /> r <br />