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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �? Telephone: (209) 466-6781 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L x4ZAJy, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete. In Triplicate) <br /> E 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 Health District. <br /> JOB ADDRESS/LOCATION L " �,i n cvha Va i(age-, W4&LU%1 -�,"� CENSUS TRACT <br /> Owner's Namet.A- Phone <br /> kir <br /> Address t City C GL <br /> Contractor's .Name License # -/LaD8 Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -[7 RECONDITION %T DESTRUCTION f7 <br /> PUMP INSTALLATION /PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �l <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE gF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial e Cable Tool Dia. of Well Excavation Ia.' o <br /> Domestic/private Drilled Dia. of Well Casing i l-4: <br /> Domestic/public p» Driven Gauge of Casing <br /> / Irrigation Gravel Pack- Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout C- 'C-vy- <br /> Disposal - - Other Other Information '' <br /> Geophysical Surface Seal Installed By: 112 � <br /> ,__PUMP INSTALLATION: Contractor PLA� <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: , / / State Work Done <br /> F PUMP '.REPA.IR:r tr a,t-.e.�._ o� Done <br /> onerk <br /> DES4RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all la end regulations of the San Joaquin Local Health District�� <br /> and the S e of Ca orale pertai ng or regulating well `'construction. Within FIFTEEN DAYS <br /> after impletion of m work on a ew we , will furnish the San Joaquin Local Health District a <br /> WELL I S REPORT the wel and ify/them before putting the.-well in-use.... .The above <br /> info ation s true th bes owfedge and belief. I WILT. CALL FOR GROUT INSPECT ON <br /> IPRIOR TO GR U ING ' A F NAL 0 . <br /> SIGNED TITLE <br /> / PLOT PLAN ON REVERSE SIDE " <br /> FOR APARTMENT USE ONLY <br /> } PHASE I � .. ��. <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: � <br /> PHASE II ROUT INSPE ION PHASE II IN INSPUT492. <br /> INSPECTION BY DAT INSPECTION BY G DAT ..�- <br /> E H 3.426 Rev. 1-74 417.5 . .2M <br />