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. 4 "AN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOE OFFICE USE: , 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ad-io 99p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 coinpliance' with San Joaquin ' <br /> th District. <br /> County Ordinance-No. 1862 andthe Rules and Regulations f the San Joaquin Local' HealADDRESS/LOCATIONJ�� ADDRESS/LOCATION 0 d? <br /> CENSUS TRACT E <br /> Owner's NameJO�A /1 A7-0.> Ts��. --w G. ,'✓I mane. <br /> Addresses . . ✓`� tGd� City <br /> Contractor's Name y��9- ���� License6�' Phon ��� <br /> 1 <br /> i <br /> NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> TYPE OF WORK {Check) ; _ _ <br /> } . PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK/Bp SEWER LINES C9 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 SPECIF C TkNS <br /> Industrial .: X Cable,Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing �U <br /> -Domestic/public { Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of,,Grout Sealy t9 <br /> Cathodic Protection 4 Rotary Type of Grout <br /> Disposal I 'Other Other Information ...„. <br /> Geophysical ' Surface Seal. Installed By: <br /> PUMP- INSTALLATION: Contractor <br /> Type of Pump H.P. .: <br /> PUMP REPLACEMENT; . / ' State Work. Done k <br /> M <br /> PUMP .REPAIR: / / State Work.Done + '""'°s """" "�� _ `\R`l4 <br /> DESTRUCTION OF WELL: Well Diameter # Approximate Depth, ^, <br /> Describe Material and Procedure�.�,- <br /> _ b r � i <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. The '4bove <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 TITLE <br /> DRAW PLT PLAN 'ON RE ERSE SIDE) . " <br /> . FOR DEPARTMENT. USE ONLY <br /> PHASE I <br /> { DATE /f <br /> APPLICATION ACCEPTED BY } <br /> ADDITIONAL COMMENTS. <br /> ' 'PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION } <br /> INSPECTION BY DATE42 r11 INSPECTION BY DATE % <br /> E H .1426 Rev. 1-74 ,F <br />