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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx.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 -7- <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 and Regulations of the San -Joaquin Local Health District) <br /> JOB ADDRESS/LOCATION 6 A/ _ZZOILA170CENSUS TRACT <br /> Owner's Name MIF C� IRE I _FLTYAr= La1L Phone - � �//Z _ - <br /> Address IZ29 OX �-� '� City <br /> Contractor's Name LIAEZ� w�ZL i LQ LIP, 0 License # . . �0 Phone <br /> TYPE OF WORK (Check) : NEW WELL "& DEEPEN -/7 RECONDITION /_7 DESTRUCTION '17 j <br /> PUMP INSTALLATION / / PUMP REPAIR '/� PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> t SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS kA <br /> Industrial Cable Tool Dia. of Well Excavation ' I <br /> Domestic/private Drilled Dia. of Well Casing <br /> iDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information <br /> f Geophysical Surface Seal Installed Byt <br /> PUMP INSTALLATION.- Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done I <br /> ' PLW tREPAIR: / / State Work Done <br /> PESiRUCTION OF WELL: Well Diameter -Approximate Depth <br /> Describe Material and Procedure. <br /> - <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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of. the well and notify-them before putting..the-wellin use.—The above <br /> informatio true to the-best of -my.knowledge and. belief. ,�I WILL CALL. FOR 'A 'GROUT INSPECTION <br /> PRIOR TQAGROUTANG AJND ARINAL IN . ECTION. <br /> SIGNED 'TITLE <br /> { (DRAW-PLOT PLAN ON-<REVERSE SIDE <br /> PHAS E I Q16 <br /> OR DEPARTMENT USE :ONLY ✓ r k,. ry <br /> APPLICATION ACCEPTBY � DATE <br /> ADDITIONAL COMMENT - -- - <br /> t <br /> PHASE II GROUT INSPECTION PHASE III/FRiAL INSPECT ON r <br /> INSPECTION BY DATE INSPEGTION'BY DATE <br /> '' E H 1426 Rev. 1-74 %r 4/75 --2M .A <br />