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Co �m �1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA;O BICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i r <br /> r Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT Permit No. rS-/96 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local stealth District. , <br /> JOB ADDRESS/LOCATION t S �r - S�C��W.esr�N�' ENSUS TRACT <br /> Owner's Name r Phone '!I <br /> Address 3 1�2 3. Al bz/! City lU` <br /> pl <br /> Contractor's Name oma. All License # ` ''Phone 56a-74 <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /? RECONDITION /7 DESTRUCTION /7!= [ , <br /> PUMP INSTALLATION / j PUMP REPAIR /x7 FUMP REPLACEMENT /7 v l <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT FRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC TELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation id <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i� <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ill <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump cc d Z H.P. z3 0 <br /> PUMP REPLACEMENT: f-1 State Work Done <br /> PUMP :REPAIR: State Work Donel-C <br /> i <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4 <br /> tin <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 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. wrell in-use.. ',The above <br /> information is true to the-best-of my owl nd belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F SPE <br /> I <br /> Q� <br /> SIGNEDITLE /•- A , <br /> W LOT PLAN 0 ERSE SIDE <br /> FOR DEPARTMENT USE ONLY I. <br /> PHASE I (�l <br /> APPLICATION ACCEPTED BY <br /> DATE_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE M/FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY A &DATE <br /> '9 Cf <br /> ,� E H 1426 Rev. 1-74 Iia <br />