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i <br /> i; <br /> y <br /> SAN JOAQUIN LOCAL 11EAL'r11 DISTRICT i <br /> n OF�'IC USE: 601 E. Hazelton Ave, , Stockton, Calif. , y <br /> 'rulephone: (209) 466-6781 7 " Ir <br /> APi i,ICATION FOR WELL CONSTRUCTION OR I'TIP F'E*11'T Permit No.i`J k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .2- <br /> (Complete In Triplicate) 44 <br /> Application is hereby made to the San Joaquin Local',Health District for a permit to construct <br /> andJor install the Work herein described. This application is made in compliance vith,:San JoagvAvi- <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health DistriCt , '. <br /> j013 ADDRESS/LOCATION y o NSUS TRACT <br /> Owner's Name Phone 6 <br /> Address 2 2. 3 L' <br /> City <br /> }, P' License / ?hone„� .� 5 <br /> Contractor's Name ��. ! <br /> TYPE OF WORK (Check): NEW VELL LV DEEPEN /7 RECONDITION /7 DESTRUCTION /7 I• ; <br /> PUMP INSTALLATION ��-PUMP REPAIR ' PUtiP REPLACEISENT L7 <br /> Other /7 <br /> DISTANCE TQ NEAREST: SEPTIC TANK SEWER LINES "� PIT PRIVY "�` mss• , <br /> SEWAGE DISPOSAL FIELD �"" CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE - PRIVATE DOMSTIC WELL — PUBLIC DQMES IC WELL . <br /> Y INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool oDia. of Well Excavation 111 ' <br /> # Domestic/private Drilled Die. of Well Casing :! >t 10, <br /> y Domestic/public � � Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout. Seal <br /> s Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical S rf ee Seal Ins ed 8 <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. �,, <br /> 4 PUMP REPLACEMENT: L7 State Work Done <br /> .F <br /> F <br /> w n_ <br /> PUMP :REPAIRS State Work Done %_,�+,✓ <br /> DESTRUCTION OF WELL: Well Diameter � Approximate Iffipth <br /> aJC6 <br /> ,Describe Material and Procedure <br /> I ereby 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 /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information>P true to the-boat of my knowledge and belief. I WILL CALL, FOR A GROAT INSPECTION <br /> _PRIOR TO GRdQTING AND NAL INSPECTION. u <br /> �].CNFsD TITLE <br /> RAW PIAT PLAN ON REVERSE SIDE . ' <br /> R ARTMBNT USE ONLY <br /> ACCEPTED 6Y J — DATE S' <br /> PHASE I GROUT INSPECTION P 3ILI17FINAL INSPECTION <br /> ")N ry DATE LINSPECTION BY DATE <br />