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SAN JOAQUIN LOCAL HEALTH DISTRICT p , <br /> FOR OFFICE USE: 1601. E. Hazelton eve . , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ./5293 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ <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.. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 . and. the .Rules an��,i1 Regul t' ns of the San Joaquin Local Health -District. <br /> JOB ADDRESS/LOCATION c , <br /> 'U TRACT <br /> Owner's Name Phone <br /> SW^.3� <br /> Address -22170 AA A <br /> City I <br /> Contractor's Name IA icense # � Phone <br /> t <br /> IJ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z&2gU SEWER LINES PIT PRIVY r...� <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA`T'IONS 4LIndustrial. Cable Tool Dia. of Well Excavation _ l� -- <br /> Domestic/private Drilled Dia. of Well Casing - <br /> Domestic/public Driven. Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal 1579 s <br /> Cathodic Protection jZ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor X, Z- <br /> Type of rump .PAc--1- G�j .v<.f . H.P/ <br /> _ f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: _ / / State Work Done <br /> DESTRUCTION 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 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 a <br /> WELL .DRILLERS REPORT of the well and notify them before putting. the. well in use.... The above <br /> infojrmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A F112L INSPE =TIO . <br /> SIGNEDLPA TITLE _ <br /> s, �.•�, . <br /> RAW PL T PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY w DATE <br /> ADDITIONAL COMMENTS: <br /> -' PHAS tGROU2 INSPECTION PHASE I. I/FINAL INSPECTION <br /> INSPECTION BY DATE 17hv INSPECTION BYljl/ DATE�2- 0�— <br /> E H 1426 R . . 1-74 <br />