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,f 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <br /> FOE OFP GE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> -" Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T6-S3�j� <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is {hereby 'mada to the San Joaquin Local Health District for a permit to construct <br /> and/orx4WStall the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and"Regulations of the San Joaquin Local Health District.. <br /> 3137' <br /> JOB ADDRESS/LOCATION 94 e . .W,trcm if)". 41 'DCENSUS TRACT <br /> Owner's Name - ��/L/Wl a4�; Phone <br /> Address ... :, I .0 L3 U City z 9s"'a ted' <br /> �.a <br /> Contractor's Name License fG 7���hone <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN /�7 RECONDITION r7 DESTRUCTION /7 ' <br /> PUMP INSTALLATION/ / PUMP REPAIR /,77 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE..-PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'- PUBLIC DOMESTIC WELL <br /> , INTENDED, USE TYPE OF 14ELL CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool Dia. of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well.. Casing <br /> Domestic/public Driven Gauge of Casing .s <br /> - Irrigation Gravel Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other 'Information - <br /> Geophysical Surface Seal Installed BY: . <br /> PUMP INSTALLATION: Contractor . �s <br /> Type of.Pump H.P. 3 a <br /> f PUMP REPLACEMENT: . /7 State Work Done <br /> PUMP '.REPAIR: /X/ State Work Donee <br /> DESTRUCTION 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 /> and the State of California pertaining to or, regulating iell "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 /> i information is true to the•bes my. o and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ` PRIOR TO TING" D A FINAL I <br /> SIGNE c,Gc ITLE B� <br /> DRAW PLOT PLAN 2LRIWERSE SIDE �. <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> r APPLICATION ACCEPTED BY DATE-., <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GRDn INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _DATE <br /> E S 1426 Rev. 1--74 r 2M <br />