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USAN LO JOA UIN AL_ ALTH DISTRICT <br /> Q � <br /> FOL:OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Permit No. <br />` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (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. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION./mW,621164 lu C / CENSUS TRACT <br /> Owner's Name `1 E <br /> Phone ?74 <br /> i Address Cita' t <br />!' Contractor's Name License # L4 6747 Phone <br />,"`TYPnOF WORK(Check) : DEEPE9 /__7 Y RECONTIOW �_ 'Yl STRUCTION-f J <br /> PUMP INSTALLATION '/7./ PUMP REPAIR /? PUMP REPLACEMENT17 <br /> Other -V <br /> DISTANCE TO NEAREST: SEPTIC TANKI160f. SEWER�LINES /C PIT PRIVY t <br /> r 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. k Cablei Too.l; ­Dia: f Well Excavation <br /> Domestic/private -'Drilled`� " I =Dia." €-Well Casing' f <br /> Domestic•/Public ➢rive�`n 4dauge of .Casing <br /> Irrigations ` ' ?'Gravel P�ckA=:-. . Dep.th of Grout Seal <br /> Cathodic pratec'ion-'_ Rotary ,Type o€ G�au[ <br /> s <br /> Disposal,-`- Other i; Other Iafarmation=% � <br /> - Geophysica` l ?, r'Surface Seal Installed 'B : <br /> j PUMP INSTALLATION: Contractor , j <br /> r t3 .. � <br /> Type of Pum .' Airyr9,. r H.P. <br /> E PUMP REPLACEMENT: / / Stare Work Done <br /> PUMP .REPAIR: State Work Done '. <br /> _ _ � --.__• Fes. � _ � � � _ -- ,� �:_..,,�y.. <br />` DESTRUCTION OF WELL: Y Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby.agree-to-comply. with-all laws-and-regulations--of-the-San-Joaquin-1dta11'-Heal'th-District <br /> and the State of-California pertaining to or ,reg4lating_well'L`construction.`1.Within FIFTEEN.-DAYS <br /> �fEe"r'cainpletion 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 FOR A GROUT INSPEr ION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED UL, * a TITLE <br /> IIQ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE_I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a, ,�"-.16 <br />! E H 1426 Rev. 144 x h/7q 2M . <br />