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f ,fJ <br /> �/ R' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rR <br /> OF, OF�CE USE: 1601 E. Hazelton Ave. , Stockton, -Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77�p6 SLA <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i <br /> (Complete In Triplicate) s <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 Soa�'']2' sk e.rC a v.,,�CENSUS TRACT - <br /> Owner's Name <br /> y Phone <br /> Address �(� fTG� �j�� City �� � I <br /> Contractor's Name License #/Fj'-7i rPhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/. . DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /-t/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY3 LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial F Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled - Dia, of Well..Casing <br /> Domes=t c/pube- _ Dxr�` G -- <br />_X Irrigation GravW1Pack �- Depth of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout <br /> Disposal Other Other Information w <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor -A <br /> Type of� Pump , H.P. <br /> a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: Jw/ State Work Done <br /> G L� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I he agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 thewell in use. The above <br /> information is true to the best of my know1 d belief. I WILL CALL FOR A GROUT' INSPECTION <br /> PRIOR TO GRO TING AND A FINAL I SP C ON <br /> SIGNED ,, } TITLE T <br /> f ( PLOT PLAN ON R RSE SIDE) ' <br /> 1 i FOR DEPARTMEN_T. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,P- <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II G UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE leg <br /> E H 1426 Rev. - I-74 %7 _ 2M; ' <br />