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SAN .TOAQUIN LOCAL-HEALTH DISTRICT - ' <br /> OArOFFICE US ., - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '" { <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �$ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Aare Issued�S- S /X� <br /> (Complete In Triplicate) r /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 /> County Ordinance No. 1862 and the Rules an egulations of the San Joaquin Local ]Health District. <br /> E <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ! dZr /1/ 01 <br /> City ' <br /> 10, <br /> Contractor's Name �- <br /> � keLicense one <br /> TYPE OF WORK (Check): NEW WELL '/ZT-'DEEPEN-/?RECONDITION /7- DESTRUCTION 4 <br /> PUMP INSTALLATION A& MP�REPAIR /-7—PUMP REPLACEMENT 17 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANKd�„z SEWER DYES PIT PRIVY *--� <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT/jo�-mss` OTHER,4,a�� <br /> PROPERTY LINE -.PRIVATE DOMESTIC WELL '^^ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE}OF WELL �..,. . <br /> Industrial CONSTRUCTION SPECIFICATIONSQ <br /> Cable_Tool Dia. of Well Excavation <br /> 0110' 7- <br /> mestic/private Dftlled Dia. of Well Casing', s ?i <br /> -- Domestic/public `Driven <br /> ,, ,,Gauge 4 <br /> ge of Casing <br /> g Pack ,,,Depth of Grout al �� <br /> ! Cathodic Protection mar {, <br /> Disposal Other TypOther <br /> Grout <br /> Geophysical - Other Information <br /> ace Sea] Instal3ed <br /> PUMP-INSTALLATION: Contractor <br /> Type of <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP 'REPAIR: -7 State WorX-D " -----�-- <br /> ,_„_ one <br /> ES'TRUCTION OF WELL: Weil Diameter Approximate Depth <br /> Describe Material and Procedure p —`�---- <br /> Ihereby agree to comply with all laws and regulations of the San Joaquin,Local Health District <br /> f <br /> and the State of California pertaining to orlregulat.ing well construction. \Within FIFTEEN DAYS <br /> After completion of my work on a new well, I will`fuish the .San Joaquin Local Health District a <br /> WELL DR RS REPORT of" the well and notify them before putting the. we11� in,,.u's'e. The above <br /> informat true to the-be s of. �. edge and belief. I WILL CALi; FORA"-GROUT INSPECTIONI <br /> PRIOR TO GR T G AND A FINAL, NS 0 <br /> SIGNED <br /> TITLE <br /> (DRA OT PLAN ON REVERSE SID - <br /> PHA I I V FOR, DEPARTMENT', tT E=ONLY - <br /> APPLI TED BY 1,az DATE - "1-7 <br /> ADDITIONAL COMMENTS: .` <br /> II A3T INSPECTI N P TII N NSPECTI <br /> INSPECTION BY DATE 6i INSPECTION BY SATE <br /> 1 # <br /> E H 1426 <br /> Rev. 1. 74 <br />