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ti 2-16-7bj' 6,�e� Alt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk .d)FFICF USE: .. 1.601 E. Hazelton Ave. , Stockton, Calif.f-5-'?8 t.,q5& NA � II <br /> Telephone: (209) 466-6781 y 5'7 5 � '�-PM NA <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L <br /> pv�t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE? �$ t`A eissued/ L 7 <br /> ',,ii�1�Gr2 Nt- -+�_�-"—f (Complete In Triplicate) �r�7•-7 <br /> Applgcation"is .]aereby 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 Joa4uin <br /> County Ordinance No. 1862 ano the s a Reguons o t Jo quip Local Health District. { <br /> � �X y4 <br /> JOB ADDRESS/LOC T10 . o r S £�5 CENSUS TRACT <br /> Owner's Name Phone <br /> s <br /> Address City <br /> Contractor's Name h License # Phone ' <br /> ILZ <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ I PUMP REPAI / I UMPr REPLACEMENT <br /> Other <br /> i <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 SPECIFIC ONS <br /> Industrial Cable Tool Dia. of Well Excavation Z <br /> Domestic/private Drilled Dia. of Well Casing ,F <br /> :Domestic/public `' Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection . ye, _ Rotary Type of Grout <br /> Disposal j Other Other Information ' <br /> 7C- Geophysical.- Surface Seal_ Installed Bim_ <br /> Ij <br /> PUMP INSTALLATION: .-Contractor - - -- <br /> s` Type of Pump H.P. <br /> PUMP-REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL% Well Diameter /l fell Approximate D p h: «0 <br /> Descr be Material and Procedur <br /> I hereby agree tp comply with all laws d regulations 6f- t-Ve"SaAAJoaquin Local Health Di triet <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above. <br /> informatis true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOio OU ING ANBA FIAL INSPECTION. TITLE�,p'� <br /> SIGNED <br /> DW-P T .PLAN "ON UVfRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'"ACCEPTED BY DATE 7/� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> E H 1426 ' Rev. 1-74 <br />