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�� _-- <br /> (d ���� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:: .q�209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/,/-- <br /> THIS <br /> /TEAS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i Date Issued <br /> t <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 /O /PjoS ��tG6G�or1,e✓ s,4 4= CENSUS TRACT <br /> Owner's Name d'I,— Phone <br /> ` Address 4-17 -'A.cat-'-f ,ems L 4- City <br /> Contractor's Name License jk Phone -t-217.1 <br /> i <br /> TYPE OF WORK (Check): NEW WELL /_T DEEPEN! /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP ;INSTALLATION /� PUMP REPAIR` PUMP REPLACEMENT /7 <br /> k Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> 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 /> Ind'u'strial Cable Tool Dia. of Well Excavation NQ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> t Disposal tt Other Other Information <br /> Geophysical q Surface Seal Installed-BY: <br /> PUMP INSTALLATION% Contractor <br /> Type of Pump H.P. <br /> r <br /> + PUMP REPLACEMENT: / / . State wWork Done ... <br /> PUMP ''REPAIR: L ` State Work Done �W hs <br /> 4ESiRUCTION OF WELL: .' .WelllDiameter Approximate Depth <br /> Dscribe Materia. 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 /> information is true, to the best of day knowled• belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED - ky-yuTLE <br /> ( PLAN ON SE SIDE <br /> } FOR•tDEPARTMENT USE ONLY <br /> F PHASE I �. Y DATE <br /> ' 10 <br /> APPLICATION ACCEPTED BY � —� l <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION P1NALINSPECTION <br /> INSPECTION BY DATE INSPECT ION <br /> BY ATE <br /> r. <br /> f� >. E H 1426 Rev. 1-74 1-74 2M <br />