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SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Ca11f, <br /> Telephone: (209) 466-6781 ' <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> JI, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k (Complete In Triplicate) <br /> Appl.ichtion �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 /> Cauaty Ordinance No. 1862 and the Rules and Regulationsofthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J O � CENSUS-TRACT <br /> {{� <br /> Phone <br /> Owner's Name 00"n- jp <br /> i <br /> a��ECity. <br /> Address 9 <br /> 522-10n�' ' <br /> t , 108 "BROS. DWI 00«0 INC. License (1 �'� Phone <br /> Contractor s Name tAIRM <br /> . : 1 <br /> TYPE OF WORK (Check) : NEW WELL ,/ DEEPEN '/? RECONDITION /_7 DESTRUCTION /7 <br /> f PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT ; <br /> Other / / <br /> II DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'—.- <br /> CONSTRUCTION ION DOMESTIC <br /> L <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> i Domestic/private Drilled Dia. o€ Well Casing <br /> :i, Domestic/public riven Gauge of Casing _ /2 <br /> 4 Irrigationravel Pack Depth of Grout Seal - - <br /> iii Cathodic Protection Rotary Type of Grout O <br /> il�. Disposal A Other Other Information <br /> ' <br /> Surface Seal Installed BY: <br /> II]. Geophysical. <br /> SUMP INSTALLATION: . Contractor C <br /> r. Type of Pump H.P. <br /> f. SUMP REPLACEMENT: / / ; State Work Done <br /> State Work Done <br /> PUMP '.REPAIR: /7' <br /> � I - - Approximate Depth <br /> EST RUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 11 liereby 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 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 /> Ii.nformation is true to the-best-of my,knowledge and belief. I WILL CALL FOR-A-GROUT INSPECTION <br /> PRIOR`TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED a (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE -2 -`.3�7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS I /FINAL INSPECTION <br /> RASE II GROUT INSPECTION DATE <br /> k ' ,INSPECTION BY DATE -1`-1' _ INSPECTION BY <br /> t 1-7�+ .2M <br /> iE H 1426 Rev. 1-74 <br /> �" <br />