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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: -1.60 <br /> FO&OFFICE 1 E. Hazelton Ave., .Stockton, Calif. <br /> ?� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I- . _ <br /> THIS-PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued <br /> .,► (Complete In Triplicate) <br /> Appiiaation ,ie 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 /> JOB ADDRESS/LOCATIONm2ot-ogiaENSUS TRACT <br /> Owner's Name Phone j <br /> Address �� `, <br /> City <br /> Contractor's Name1 449141 S1"a <br /> License :j (J Phone p3 <br /> -10 �a {f <br /> 117 <br /> TYPE OF WORK (Check),!,�,NEW WELL ffiffj�-DEEhN /-7sRECONDITIONS/� ' /DESTRUCTION f <br /> PUMP)INSTTION / / PUMP <br /> REPAIR PUMP :REPLACEMENT <br /> Other. # a <br /> DISTANCE TO NEAREST: SEPTIC_T`NK <br /> i SEWER LINE- -+ -PIT PRIVY <br /> „SEWAGE DISPOSAL-FIELD ���CESSPOOL/SEEPA,GE pITr` 4 <br /> . PROPERTY`LINE- PRYNyATE-DONESTZC EL '� : •i. -OTHEK� ` <br /> INTENDED USE L PUBLIC DOMESTIC WELL' (,J <br /> �l k TYPE=OFa WELL`i Mkt' ; GONSTRUCTION�SPECIFICATIONS,' ► <br /> Industrial � .� �I.Cable Tool Dia. of Well 'Excavatioxf. ` rrd {� <br /> ,_ Domestic rivat6)'. -� ` � l <br /> /p `�� ' _ Dr`.i 1ed � Dia. of '.Well Casing 'mil r '> r <br /> Domestic/publi if " --.�t Driven] Gauge of Casing f` r . .. +� .- vN <br /> Irrigation �`�, ng <br /> Depth of Grout Seal ."' f� (mfr <br /> Cathodic Pzotecti-4 �,I t�otaryi ­Type-of�rout I <br /> Disposal G . = - Other <br /> Other in'iormation �� 14 <br /> Geophysical Nom. _ ".l <br /> -. Surface Seal} .In"s`talled B : `� t <br /> PUMP INSTALLATION. l '1 r <br /> Contractor <br /> Type of Pumpi ! � <br /> PUMP <br /> REPLACEMEiVT / State.�Work�Aonen <br /> PUMP 'REPAIR: y -----------�- r <br /> 1-7 state Work Done <br /> E&TRUCTION 0 WELL: Wel 'L46ter <br /> ry Approximate Depth <br /> cr e d Procedure -, <br /> � <br /> I hereby agree to Jco�nply w th a 1 laws and re ati 1 <br /> g o of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS t <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 my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ` <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: TN <br /> PHASE II GROUT INSPECTION PHASE III FIN <br /> INSPECTION EY AL INSPECTION <br /> ASE _ 7S INSPECTION- BY ' DATE <br /> E H 1426 Rev. 1- <br /> 74 <br /> _ 9_76 lbs <br />