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P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT TOT.;".6'F-F—1C E USE:` 1601 E. Hazelton Ave. , Stockton;- 'Calif.- ! <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3z�W, t <br /> (Complete In Triplicate) - <br /> Application is hereby shade to the, San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is shade in compliance with San 3oaquiii <br /> : County1Ordinance No. 1.862 and -the Rules and Regulations of the San 'Joaquin Local Health District. <br /> 16 0 <br /> JOB ADDRESS/LOCATIONy '� ` i�` CENSUS TRACT . <br />�. Owner's Name 17 i I L Phone <br /> Address jib W a i1L City <br /> Contractor's Name aL I LL ° kl� b License # Phone S <br /> TYPE OF WORK (Check) : NEW WELL J)t DEEPEN / .RECONDITION DESTRUCTION f7_ PUMP-INST LATIOH /�/ PUMP-REPAIR':/ / PUMP REPLACEMENT /� <br /> ,DISTANCE NEAREST: SEPTIC TANIC AV: SEWER LINES /o*t PIT PRIVY <br /> w, SEWAGE DISPOSALJIELD ­.CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC'WELZ'.-L PUBLIC DOMESTIC WELL <br /> INTENDED'USE a TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool, Dia. of Well Excavation . /0 '� <br /> �- Domestic/private —Dr111ed1 W--. W e11 Casing 6�' <br /> o <br /> --Domestic/public Driven - , Gauge of Casing At I 2A <br /> t� <br /> Irrigation Gravel Pack ' } ' Depth of Grout Seal <br /> ti Cathodic Protection L/ , Rotary Type of Grout-, �BC U rF 6 <br /> Disposal "^ Other - _- =°Other Information <br /> Geophysical Surface Seal Installed By:- p EA <br /> PUMP INSTALLATION: Contractor <br /> �. MType of Pump , _ H.'P. t <br /> f <br /> PUMP REPLACEMENT: / /- State Work Done �t " <br /> PUMP REPAIR: / / 'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc-ribe 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 pertaining to or regulating well'iconstruction. 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 MPORT of the well and notify them before putting..the..well<.-in.use:... The above. <br /> information iA knrue to t b st o know dge andbelief, I WILL CuA�LL_FOR-A-GROUT INSPECTION <br /> PRIOR TO GRDU G AND A IN N O'. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON,REVERSE SIDE <br /> _ FOR DEPARTMENT USE ONLY <br /> F z <br /> PHASE ,I "nJJ <br /> APPLICATION ACCEPTED BY / r a IC- hT DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE,,11t O IP8P8CTIW PHASE III IFINAL INSPEC ION <br /> INSPECTION BY DATE C� INSPECTION BY DATE ' i <br /> F R 1L26 Ron_ 1-76 <br />