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ti K <br /> • If)AQUIN LOCAL. HEALTH <br /> OR OFFICE UfiE:--- i ( ' L6OI i•:, Ilazelton Ave. , Stockton, Caiti. <br /> rulephone: (209) 466-678- _ <br /> �- API"ACATION FOR WELL CONSTRUCTION O%I 7ermit ho. Z.I-j_LZI-1 <br /> TIiiS PERMIT_ EXPIRES 1 YEAR FROM DATE ISSU_F_D Date Issued <br /> (Complete In Triplicate) ~ <br /> >plicatiort is hereby made to the San Joaquin Local Health District for a permit to construct y <br /> td/or inscall the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 attd the Rules and Regulations of the Saa Joaquin Local Health District. <br /> )B ADDRESS/LOCATION--tj)_'61-k�m . _,CENSUS TRACT r <br /> 1:�r/u,4C'rLG't'�t l'v <br /> Owner's Name Phone _ 'Z-> <br /> ) 1 t - City <br /> Contractor Name [ NL{ S . ;L •, License # ..: Phone Y?? <br /> 411 <br /> CPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION g `-A <br /> PUMP INSTALLATION /-J PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> l <br /> Other / / N <br /> -"-� PIT PRIVY <br /> � <br /> T_STANCE TO NEAREST: SEPTIC TANK.�,�.� SEWER LIPIES%,,t��;�r� <br /> SEWAGE DISPOSAL FIELD CjSSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINF - 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 Crout Seal <br /> Cathodic Protection -L Rotary Type of Grout <br /> Disposal Other _ Other Inforwati.on2t�J <br /> Geophysical Surface Seal Installed By: ! <br /> rUMP INSTALLATICN: Contractor <br /> -)e of PumpH.P. <br /> UMP REPLACEMENT: i State Work Done . <br /> PUMP .REPAIR: / State Work Done - <br /> k" <br /> ES•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 s <br /> tnd the State of California pertaining to or regulating well constriction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquir: Local Health Distxict a <br /> 'JELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> '.nformatior, is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TC GRO"TING •ANL A FINAL INSPE ,ION.• <br /> SIGNED r. ` - ;' Iz <br /> y TITLE4j.,ERSE SI <br /> cr <br /> —' <br /> FDA DEPARTMENT USE ONLY <br /> ?RASE I - J <br /> APPLICATION ACCEPTED BY ---_ -- � 'i%l- cc /_, DATE - <br /> ADDITIONAL COM-ZNTS: _ - <br /> PIU1iT INSI'F_,CTION P E�� I/FINAL INSPECTION ..., <br /> It'.03ICTION BY — - D;,T - �� INSPECTION BY �, DATE s - <br /> x; <br /> L <br /> E 11 1426• Rev. 1-1 • 1-74 2M <br />