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SP TOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> _iOA OFFICE USE: 1601 Z'! Hazelton Ave. , Stockton, Califf- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> Runty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION 23A4.# iqyl!l I SO CENSUS TRACT <br /> mer's Name m A f --iwi ScAv.tE2 Phone $&$a977 <br /> idress SArriE City �$CA�^ ✓ <br /> ontractor's Name 7-/7 S✓#ao 4 SoaJ License #,229010 Phone <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR & PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed B <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done // p <br /> 'UMP .REPAIR: State Work Done fi f)0 Plje- -40 �cih Tc�m� <br /> CS•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ]ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .nformation is true to the best of my knowledge and belief. I WILL CALL OR A GROUT INSPECTION <br /> RIOR TO GROU NG AND A FIN INSPECTION. <br /> ;IGNED • _ TITLE <br /> —�' (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> ?HASE I <br /> 1PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: (=? <br /> PHASE II GROUT INSPECTION PHA§ ' I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 7 DATE v-/3 95 <br /> E H 1426 Rev. 1-74 1-74 2M <br />