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II '` *�~SAVJOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR TOFF ICE"USE": 1601 E. HAze1"t6n.Ave. , 'S"tockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT. EXPIRES'I:�,YEAR�:FROM DATE ISSUED Date Issued <br /> :(Co Tete ;In Tri f . �' .L.. <br /> mp plicate} . . ;K <br /> Application is hereby made to the Sad it paquin'Local Health.District for a permit to construct f <br /> and/or install the work herein described. , This applicaiion:ais, made. in compliance with San Joaquin <br /> County Ordinance No.: 1862 and. the=Rules-Nand Regulations of .the San Joaquin Local -Health District. <br /> JOB ADDRESS/LOCATIONT + ,* , <br /> �,. CENSUS TRACT <br /> Owner's Name N <br /> a :? . � " -. . <br /> ' Phone <br /> Address J _ _ �. <br /> city � eG/�7-aA <br /> I. 1 <br /> Contractor's- Name r - [' �, License # ZLZdz Phone ,�- <br /> I� F <br /> TYPE OF WORK (Check): NEW WELL Af DEEPEN 17 RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION I/ PUMP REPAIR /_7PUMP REPLACEMENT 2 f .� <br /> Other / / <br /> t <br /> DISTANCE TO NEAREST: SEPTIC 'TANK _SEWER LINES. PTT-.PRIVY <br /> _ <br /> _ <br /> _..'SEWAGE DISPOSAL FIELD T CESSPOOL/SEEPAGE PIT T <br /> OTHER <br /> PROPERTY LINE--—PRIVATE DOMESTIC WELL'' PUBLIC -DOMESTIC WELL '. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Iniiustrial F. Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well_.Casing & <br /> Domestic/public Driven Gauge of-CasingZ . 1 <br /> Irrigat , 'Gravel Pack 'Depth of Grout Seal <br /> Cathodic Protection _Rotary----• --z—Type-of Grout'- <br /> DisposalOther Y ` Other Information <br /> Geophysical Surface Seal Installed BY: ' <br /> PUMP INSTALLATION: Contractor <br /> ;Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work°Done~ <br /> PUMP `.REPAIR: /7 State Work-Done <br /> ES;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 San Joaquin Local Health District <br /> and the State of- Calif ornia.-pertaining-tcr-or-regulat,ing we17 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 TOR 'A 'GROUT INSPECTION <br /> PRIOR TO 'IG TING �IkA Y <br /> A#7 ,i ECT TON:' <br /> SIGNED f<< TITLE <br /> .,rr/YJli <br /> � W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY y j <br /> TEG <br /> ADDITIONAL COMMENTS: <br /> II" PHASE II G E�CTION P INSPECTION <br /> INSPECTION BY —DATE INSPECTION BY TE p - <br /> E H 1426 Rev. 1-74 ! <br /> 1-74 2M <br />