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e� <br /> JOAQUIN .LOCAL HEALTH DISTRICT <br /> f'OE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �j Telephone: (209) 466-6781 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> . r 22o 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 9_ - <br /> it (Complete In Triplicate) <br /> Application is hereby made.4to the Sari Joaquin Local. Health District for a permit to construct <br /> p and/or install, the work herein described. This application is :node in compliance with San Joaqui <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI cam: J CENSUS TRACT <br /> Owner's Name p IVB Phone ' e <br /> izzgga <br /> Address <br /> # CityAk <br /> Contractor's Name <br /> a nJ License Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/_7 RECONDITION /_7 DESTRUCTION <br /> { PUMP INSTALLATION /-7PUMP REPAIR ' <br /> IST PUMP REPLACEMENT <br /> Other <br /> E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'tib PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSk00L'/•SEEPAGE PIT OTHER <br /> PROPERTY .LINE = PRIVATE DOMESTIC WELL ' • PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL u CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia.-of-Well Excavation <br /> Domestic/private Drilled Dia... ofrWell Casing C <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Graver.-Pack Depth-of-Grout-Seal--- <br /> Cathodic Protection Rotary, � .,; Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATIONS Contractor <br /> Type 'of Pump H.P <br /> PUMP REPLACEMENT: • / 'i State'Work Done <br /> u <br /> PUMP .REPAIR: /�% <br /> :State Work Done y <br /> F y � <br /> � DE&TRUCTION OF WELL: Well -Diameter <br /> Approximate Depth: <br /> Describe- Material and Procedure A . <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 anew 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 /> information is true to the-best.-of my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG UT NG ' D A 'VINAL INSPECTION. <br /> ( SIGNED L&4& TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> , PHASE I R DEP AR T USE ONLY <br /> APPLICATION ACCEPT B /Y' DATE � �ZZ <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION HY DATE/,? <br /> E H 1426 Rev. 1-74 r :,/,7c ow <br />