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1p l� C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA1rOFFICE USE: llf��� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> iM _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> iM <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,2 -7�t <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 compliance with San Joaquin <br /> Cou' y Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION �" °l 6 f /�jqL-rall u rs CENSUS TRACT <br /> Owner s Name )z ,_o ✓ Phone <br /> Address92f 42 'kif 0/4 City <br /> Contractor's Name ! License # LaL Phone <br /> I11 10V <br /> 4 <br /> TYPE1OF WORK (Check): NEW WELL -/-7 DEEPENT7 /-7ALRECONDITION /-7 DESTRUCTION / <br /> PUMP INSTLATION PUMP REPAIR /-7 PUMP REPLACEMENT j5?T- <br /> Other <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 0 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> iM Domestic/public Driven Gauge of Casing <br /> 1 Irrigation Gravel Pack Depth of Grout Seal , <br /> i 11. Cathodic Protection Rotary Type of Grout <br /> !f Disposal Other Other Information <br /> iM Geophysical Surface Seal Installed- AX: <br /> PUMP INSTALLATION:. Contractor <br /> 'Type of Pump b R.P. <br /> PUMP, REPLACEMENT: State Work Done ..tet <br /> ,� �/ ,t.�) ..� <br /> o.- .r <br /> PUMP�REPAIR: /7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> andf'he 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 puttingthe. well in-use.. The above <br /> information is true to the-best-of my.knowledge,.an belief. I WILL CALL FOR,A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE i N. --_ . . _ - <br /> SIGNED -TLE <br /> �I { RA PLOT PLAN ON REV SE SIDE <br /> j� FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C/`� DATE Y r J <br /> ADDITIONAL COMMENTS: <br /> I� PHASE II GROUTT -INSPECTIONPHASE III FINAL INSPECTION <br />• INSPECTION BY DATE INSPECTION BY DATE !� <br /> 4 E H 1426 Re - <br /> v l 74 1-74 2M <br />