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_ SAN JOAQUIN LOCAL HEALTH D_STRICT �' G l <br /> { <br /> ?(J; OFFICE JE* <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR FL'tP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.Z—s-7U a <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ThLs application is made in compliance With San Joaquin <br /> b County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> `f <br /> JOB ADDRESS/LOCATION I� ���lb' CENSUS TRACT <br /> Owner's Name —le A-1 / L i 3 Phone 76 e, <br /> Address. ��e 2' City Z: CT fo pj <br /> Contractor's Name -OT�� 1-�� rli�• - '715, Lzt;.:use #/4X 3 3phon <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN /_j RECONDITION /-j DESTRUCTIONL7 <br /> PUMP INSTALLATION / / PUMP REPAIR J7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER LINES PIT PRIVY` SEWAGE DISPOSAL i�IEi,D CESSPOOL/SEEPAGE FIT OTHER <br /> PROPERTY LINE - PRIVATE TX?MESTIC W_FLL —_ 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 }given 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 By: � • <br /> PUMP 717STALLATION: Contractor <br /> Type of Pump H.P. <br /> r-UMP REPLACEMENT: / / State Work Done <br /> { — <br /> & }k'; PUMP .REPAIR.: State Work/VA -- �q <br /> rRES•TRUCTION OF WELL: Well Diamete- 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 /> firsand the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District as <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 INSPECTION <br /> PRIOR TO GROUTING A14D A FINAL INSPECTION, <br /> SIGNED _ TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: -s--, <br /> PHASE II GROUT- INSPECTION PHA E I F NAL INSPE(.'TION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1•-74 1-74 2M <br />