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SAN JOAQ TRS L(rGTEALT � .�"°" — ------- <br /> FOHrflFFYCE USE• H DISTRICT <br /> .1601 E. Hazelton Ave. , .S.tockton, Calif. <br /> Telephone: (209) ,466-6-781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> TMS PERMIT EXPIRES 1 YEAR 'FROM DA <br /> T TE ISSUED Date Issued' y �r <br /> �o75:, (Complete In .Triplicate) _ <br /> Application is hereby ,mide 'tc the San Joaquin Local Ileal th District for a permt to- construct <br /> and/or .install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance Na. 1862 az�d the Rules and Re u at o of- the SanJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION K SUS TRACT <br /> Owner P s Name <br /> Phone <br /> Address l �N <br /> [ City <br /> Contractor'sGc eG . <br /> Name H Licensern <br /> Phone <br /> Me <br /> TYPE OF WORK (Check): NEW WELL 'Zg DEEPEN/?Pi1I� REPAIR RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /_7 <br /> I / /I PUMP <br /> Other !E/- i7 <br /> /% . <br /> r t <br /> 3DISTANCE TQ NEAREST: SEPTIC �TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDTSPOSAL FIELD CESSPOQL/SEEPAGE FIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> DCable Tool Dia. of Well Excavation <br /> Omestic/private Drilled <br /> Domestic Dia. of Well Casing a <br />.rt. /Public Driven ._�, ::Gauge o€_Casing <br /> Irrigat;i ion r� Graved. Pack Depth of Grout Seal <br /> ..,�_ Cathodic Protection 1 Rotary <br /> Disposal � Other Other Information <br /> Geophysical <br /> - .. <br /> PUMP INSTALLATION: Surface Seal Installed B' : . <br /> Contractor <br /> Type of Pump <br /> ,t H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done ;, <br /> PUMP !REPAIR: <br /> L-7StateWork Done <br /> ES;TRUCTION OF WDLL: Well Diameter C <br /> Describe Material and Procedure Approximate Depth �T <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 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.. <br /> 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 /> SIGNEDng-g � <br /> ILV TITLE t <br /> DRA PLAT PLAN ON VERSE SIDE o _� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CONIMENTS: DATE 4105 <br /> P SE II G OUT INSPECTION <br /> INSPECTION .BY P SE IIY FINAL INSPECTION <br /> DATE INSPECTION BY, DATE 3 <br /> . E H .1426 r Rev. I-74 '� <br />