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1 T.i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA('OFF'Zw_ CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zla-)-174{ <br /> c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2z& <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Realth 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. Iealth District. <br /> JOB ADDRESS/LOCATION �f` C'�i �rl. ^ 5 ,�'''� ij�= /�'�' /y/D,tt'/I ' CENSU TRACT <br /> '- —� <br /> Owner's Name * Phone-/W 9.3,E <br /> 0 01 <br /> Address r City <br /> Y, 4 <br /> Contractor's Name License Phone. <br /> E <br /> TYPE OF- WORK (Check): NEW WELL /Lj--DEEPEN . _7 RECONDITION / j <br /> __7 DESTRUCTION f <br /> PUMP INSTALLATION _PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK ,ol6 4 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 k/__--Cable Tool Dia. of Well Excavation <br /> s &- Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .1 Rotary Type of Grout F-S 4 C • <br /> Disposal , A Other Other Information <br /> GeophysicalSurface Seal Installed By: <br /> . '4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ - - - - H.P. <br /> PUMP REPLACEMENT: f / State Work Done __ <br /> PUMP 'REPAIR: J 7 State Work Done <br /> PES TRUCTION 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 regul'a ing 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. •tkie'well sand 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 TOG T G AND AFjgAL -INSPECTION. <br /> SIGNED x. TITLE i ,f <br /> DRAW PLOT PLAN-ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;; f <br /> APPLICATION ACCEPTED�IBY`:4�-:. DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I GR UT INSPECTION 7 PHAS III F NAL INSPECTION <br /> INSPECTION BY _. DATE INSPECTION' BY DATE <br /> 'E H 1426. . Rev. ��1 7 4 -. � � � � � ��` -R A Al Ir-7412K <br />