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' Co vt� yds /� ••G`�.�-� <br /> SAIIN LOCAL HEALTH DISTRICT <br /> FOR.OF II CE USE: 1601 E. Hazelton. Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Ido. ( ' <br /> THI'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ZZ-3 - 05'0 - 31 <br /> Application is ,Aereby 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 Joaquini <br /> County Ordinance No: 1862��3ndy-the Rules and Regulations of the San Joaquin Local Health District. I <br /> ,r/ 1`,,.` { �e.�•,.e��T�� �-�.�'-«,�a-�-,-e- SGvv <br /> :TOB ADDRESS/LOCATION. /ro.�i�'.� f �.S'�LplY�srl � Q+���� CENSUS TRACT <br /> Owner's Name' ,; A. 4e-/- 6-P Phone <br /> Address . <br /> city - <br /> Co I n' tractor's Name .- - .License ��)�hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION % / PUMP-REPAIR / PUMP REPLACEMENT /-7 <br /> Other <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY h <br /> SEWAGE 4DISPOSAL 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 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -- <br /> ___ .K Irrig t an- x Gravel Pack. -- Depth-of Grout"S_eal 7 - <br /> r. Cathodic Protection_ 'Rotar.y Type of Grout <br /> Disposal - Other I iOther Information <br /> Geophysical Surface SealtInstalled By <br />' PUMP INSTALLATION: Contractord <br /> Type of Pump H P ;�s C) <br />, PUMP REPLACEMENT: /`/ State Work Done.,,,�x . <br /> PUMP ;REPAIR: f / State Work Done r /S <br /> DES'.TRUCTION OF WELL: Well Diameter # Approximate Depth <br /> Describe' Materialland Procedure <br />° I ii reby,agree `to co ply with all laws and regulations of the San Joaquin LocalHealth iatric"' <br /> an'd 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.mysknowledge and_b .elief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO GROU ING-ANTI A -FINAL INSPECTS IV, <br />)SIGNED ITLE <br /> (D WjjEOT .P AN ON REV SE SIDE) w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '-•- .. <-. . L _ <br /> APPLICATION ACCEPTED- BY $ . � <br /> }DATE =` �/- 7 /, <br /> ADDITIONAL COMMENTS: i <br /> PHASE. II GROUT INSPECTION PHA j I ,FINAL INSPECTIO <br /> INSPECTION BY DATE ,. INSPECTION BY DATE <br /> E H 1426._ Rev. 1-74 117.7 _ 2M <br /> t _ <br />