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4 SAN JOAQUIN LOCAL`-HEALTH DISTRICT <br /> FOR OFFin USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 466-6781 '7 I� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date.Issued`��7-7 <br /> (Complete In Triplicate) <br /> Application is hereby made tothe San Joaquin„Local Health District €or .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 Joaquirn ,Local Health District. <br /> 70B ADDRESS/LOCATION #Q S►, /vene A `� <br /> CENSUS TRACT . <br /> Phone <br /> owner's Name <br /> City.. � ---�- <br /> AddressVZ5_ <br /> Contractor's Name Bim _ <br /> License # �ga3'�hone 7� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / 1 RECONDITION /__/ DESTRUCTION <br /> PUMP INSTALLATION / I FUME REPAIR / PUMP REPLACEMENT I / <br /> Other I/. / T .- <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 <br /> Domestic/private A Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �c Irrigation { i Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal t_ . i Other 'Other Information <br /> face Seal Installed B <br /> Geophysical Sur <br /> ,PUMP INSTALLATION: Contractor <br /> Type of Pump `T".c� r%' �M� _� H.P.. 2 <br /> S” <br /> A _ <br /> <PUMP REPLACEMENT: / / - :State Work Done <br /> f ti <br /> PUMP .REPAIR: State Work Done p f `"' <br /> ` r � .- :. •, � �.� �/ Approximate Depth fr <br /> ADESTRUCTION OF WELL: \WellDiameter <br /> f iibe 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 'pertai.ning 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;Iwell and notify them before putting. the. well in use. The above <br /> E <br /> i 'fiformation is true 'to the ties.t of~my kj}owledge-and-belief 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL. INS EC� Obi. <br /> SIGNED „n,n.� TITLE: <br /> (' RAW PLOT PLAN ON R VERSE SIDE) <br /> V FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: A PHASE III/FINAL INSPECTION <br /> PHASE II GROUT) INSPECTION <br /> INSPECTION BY 't DATE INSPECTION BY Ae DATE/ 8 <br /> h i,/77 2M <br /> V u TL9A T2av_ . 1-74 <br />