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GLet�+�e✓'fo po-u•✓ Ge-h-04-09 <br /> b m 1.0�.� r�-►'"'] bei t o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. � <br /> /ss a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_�c7_�� <br /> }I (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 /> .TOB ADDRESS/LOCATION <br /> No i'��C �as' a ' O`RaF104•tc 646 CENSUS TRACT <br /> / i <br /> Owner's Name `&ot- t. 400//.j Phone <br /> , <br /> Address vep <br /> d ip City GVZ7 <br /> Contractor's Name' J00 j +, <br /> License # �}Phone y <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/_7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7—pump REPLACEMENT j <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 i Cable Tool Dia. of Well Excavation V <br /> .Domestic/private i Drilled Dia. of Well Casing <br /> �,�� Domestic/public P : Driven Gauge of Casing: <br /> irrigation r Gravel Pack Depth of Grout" Seal 3 <br /> Cathodic Protection jRotary Type of Grout <br /> Disposal i Other' Other Information ' <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done o VL u.r <br /> PUMP ,REPAIR t <br /> . /7 •State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter A ' roximate <br /> pP Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use... The above <br /> information is true: to the b fy . a and belief. I WILL CALL VOR',A-GROUT INSPECTION <br /> PRIOR TOG UTING AND A FIN IN ON. ._ <br /> GNETITLE 'A 10" <br /> D PLOT PLAN O REVERSE SIDE - - <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATF ��iC? t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />