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L:.Il JUliy' ?f7 LOCAL 11EALT11 D I FTP IC t <br /> FOR"OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telepbone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4- <br /> (Complete <br /> -(Complete In Triplicate) <br /> Application is hereb;• made to the Sala 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 �� 2 J'U ��i w ,' L /f ll Lt fc"�'�:��%� CENSUS TRACT <br /> Owner's Name �i �� ��r lli. /%f<<c /c r Phoneme <br /> / <br /> Address T��- 1 6 ) ��. �u -t y /7 L' .� P���/: City /6�47n 11e", <br /> e", <br /> Contractor's Namea License <br /> fY �� <br /> TYPE OF WORK (Check): NEW WELL /77' DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / 7 PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY I,INE - PRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS !� <br /> Industrial Cable Tool Dia. of Well Excavation (t <br /> Domestic/private y Drtlled Dia. of Well Casing -% <br /> Domestic/public Driven Gauge of Casing <br /> ation Gravel Pk Depth of Grout SealIrrig <br /> ;c <br /> Cathodic Protection _ Rotary Type of Grout f'�� z Tom, <br /> E 7-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> ,DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the an Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. W!thin FIFTEEN DAYS <br /> after completion of my work en 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 INSPECTICN <br /> PRI <br /> TO G TOUTING AND A FINAL INSPECTION. <br /> SIGNED F< -�� '� TITLE <br /> (1}?tAW PLOT PLAN ON REVERSE SIDE <br /> -- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY __-- <br /> ADDITIONAL COXD'EN:S: ply F I FINAL INSPECTION <br /> PNAS GROUT INs, CTION INSPECTION B1 w DATE <br /> INSPECTION BY� DATE — <br /> 1-74 2M <br /> E H 3.426 R.-.v. <br />