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r ,uF r� �• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OMCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> 110171 <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the RulesandRegulations of :the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION / t!G � / AlN �� ,�„ ra- d r :� CENSUS TRACT - --_- <br /> Owner's Name S [Ag l Cd)?_ --L � Phone <br /> Address' City Il '�.► <br /> Contractors Name � /( R- ' License #/ -7s;�Phone 64C 71,7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / ./ RECONDITION ./_—/ . DES TRJJCT1-ON_./__7 _ _ <br /> PUMP INSTALLATION LX1 PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other! / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK -SEWER LINES PIT PRIVY (^ <br /> SEWAGE` DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT r OTHER eL� <br /> PROPERTY. LINE - '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 1 Driven Gauge of Casing <br /> Irrigation I .Gravel Pack Depth of Grout Seal <br /> Cathodic Protection E Rotary, Type of Grout <br /> Disposal ! Other Other Information <br /> Geophysical. I _Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor t-�-< <br /> Type of Pump f H.P. '1--- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP. / / ,.State Work Done hfa)�/ <br /> - <br /> DES•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 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.wrell and notify them before putting. the. well in use... The above <br /> 'information is true to the best of. my knowledgeT a�ah belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FINAL INP C 0 <br /> SIGNED ITLE STI' , <br /> ' ro <br /> (DRAW PLT PLAN ON RIWERSE SIDE) <br /> i <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4 APPLICATION ACCEPTED BY DATE a /p 7 <br /> e :ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION P I/FINAL INSPECTION pp�� <br /> INSPECTION BY DATE INSPECTION BY BATE -� '�O <br /> t <br /> E H 142.6 Rev. . 1 -74 <br /> 6177 _ 2M <br />