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Ik, <br /> • ' � � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.,•OFFICE:' SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y- 3 4i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 2-;01-7C/__ <br /> E q (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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION X_.z D 9' ] S. S,C�L[.� __•.. &A "A_`oC „- CENSUS TRACT <br /> Owner's Name <br /> Phone3-7 <br /> -Address <br /> j - City <br /> Contractor's Name t License # Phone <br /> -TYPE--OF­WORK::(Che ck)=:, NEW.WELLVZF/=DEEPEN--/77RECONDITIONt/77--PL-DESTRUCTION-/ jam^ <br /> PUMP INSTALLATION /-7 PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK loee 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 Cable Tool Dia. of Well Excavation " <br /> ii Domestic/private Drilled : Dia. of Well Casing n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal A 6 Other, Other Information <br /> Geophysical `--j Surface Seal Installed B *-.. <br /> PUMP INSTALLATION: Contractor f " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L7 <br /> Work Done <br /> ESTRUCTTON OF WELL;...'�t4l et <br /> er _ Approximate Depth <br /> � . Describe Material and Procedure <br /> I hereby agree-, to.,comply with all laws and regulations of the Sar: 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 above <br /> information is true to the-best-of. my:knowledge and belief. - I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING MD A FINAL" SP. ION. -. <br /> SIGNED AuluTITLE <br /> KRLM PLO PLAN ON ROVERSE SIDE <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY ,� DATE �Z Z� <br /> DITIONAL COMMENTS: / <br /> I PHASE II GROUT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> .E H426 Rev. 1-74 1-74 2M <br />