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�Ur xo�16 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --j0--%iO1FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .-4 _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 -ihe San Joaquin Local Health District. <br /> 0,0P106,? .r w <br /> JOB ADDRESS/LOCATION W&4- S;IAII I-r&14 7;Ctq 7 AOA490A W dCENSUS TRACT <br /> r <br /> Owner's Name r Q """" Phone <br /> Address 1100 C � 1 �. City <br /> Contractor's Name Z� rde License # A3 72►Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /}C/ PUMP REPLACEMENT _/-7 <br /> Other f-1 <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/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 /> Geophysical Surface Seal installed By: <br /> PUMP INSTALLATION: ContractorY'7�ttJal/ k t <br /> Type of Pump H.P. V4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: f)C/ State Work Done _,ft e.r eV,,# 9.- $a -J%O VO <br /> 4ES RUCTION 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 furcaish the Sala 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 INSPECTION <br /> PRIOR TO GE2U ING AND A FINAL NSP,ECTrIO r <br /> SIGNED ,. TITLE 1' <br /> ffl=�P!OT PLAN ON MERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY, Z244j,61AZ DATE � � <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE p <br /> `� ~E H 1426 '. Rev. 1.74 1-74 2M <br />