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/.1601 <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: E. Hazelton Ave. , Stockton, Calif.i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. U/ <br /> THIS PERMIT EXPIRES. I 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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> it <br /> JOB ADDRESS/LOCATION IQK TD Al CENSUS TRACT <br /> Owner's Name -S/M,0407- SO L 1 L E -SPhone Z 1 <br /> Address } T� <br /> 2 2 �!/ .E'Y III City <br /> Contractor's Name O G G, License #;Z 9Z?jPhone !74 $'LI <br /> :j <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN '/—/ RECONDITION /_� DESTRUCTION /_7 <br /> � <br /> PUMP INSTALLATION ' PUMP REPAIR '/—/ PUMP REPLACEMENT /_ <br /> Other �/ / <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK 30 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �X Industrial Cable Tool Dia. of Well Excavation j p �� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ - _=i ,__Driven ;� ._ --- LGauge::_of_Casing <br /> Irrigation Gravel Pack Depth of Grout Seal , ' <br /> Cathodic Protection Rotary Type of Grout _ CE,va Fn•z <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor A10 AC,Ft c" <br /> Type of Pump 5'u _R)U/BLSH.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> - — F t <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION 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 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..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 GROUTING ANDA F ALJINSPECTION. <br /> SIGNED TITLE C..� <br /> D W PL T PLAN ON RE FRSE SInE) "" '��-- 7�:1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> APPLICATION ACCEPTED BY DATE �` 7/7 <br /> ADDITIONAL COMMENTS: <br /> PHAIVU AOUTINSPECTION PHASE III/FINAL INSPECTION j <br /> INSPECTION BY DATE —�P INSPECTION BY w DATE �o y <br /> s <br /> E H 1426VvII-74 3�7� <br />