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JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOA OFFICE USE: 160 , Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � �J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San JoaquJ <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the Sann� Joaquin Local Health District. <br /> OB ADDRESS/LOCATION _ f ~// t9 �Q�� / iu � �D �CENSUS TRACT <br /> aner's Name �Dytp�� rc Phone 34a L9 <br /> 3dress /,� �/, „/ <br /> City <br /> antractor's Name �• cense 11029083 Phone <br /> iPE OF WORK (Check) : NEW WELL /V DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK Zd O SEWER LINES Z 00 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 r Dia. of-Well Excavation �l <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing Q 1/J, <br /> _ Irrigation Gravel Pack Depth of Grout Seal _ / <br /> Cathodic Protection _ X Rotary Type of Grout <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Installed B <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> JMP REPLACEMENT: State Work Done <br /> JMP REPAIR: /% State Work Done <br /> ?STRUCTION 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 /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> [ter completion of my work on a new well, I will furnish the San Joaquin Local Health District 1 <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> aformation is true to, the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 2IOR TO OUTING AND A FI AL INSP CT IO . <br /> IGNED <br /> TI <br /> DRAW LOT FLANLON REVERSE E) <br /> OR DEPARTMENT USE ONLY <br /> MASE I <br /> PPLICATION ACCEPTED BY DATE Z 7R <br /> DDITIONAL COMMENTS: <br /> PHASE W GR4OUT INSPECTION PHA II/ INAL INSPECTION <br /> VSPECTION BY p_DAT_E —6' 7 INSPECTION BY DQATT-E�O <br /> E H 1426 Rev. • 1-74 3_7-7f1 *' o "^"'/'�`r;.f �hl //{ <br /> 77 n,`rQ''. <br />