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qAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POR OFFICE USE: 16�E. Hazelton Ave. , Stockton, Cam. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7(g <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .id/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and <br /> the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION�'� �( <br /> . M&LLnk g-�1)!.f &j 9 - �-TRACT <br /> ^vner's Name ' hone n <br /> `ASdress City rQPQ A(yT / <br /> 3ntractor's Name '1C l (3 License # � ,4.9/.3Phone �j�?-%/3 / <br /> tPE OF WORK (Check) : NEW WELL /FO' DEEPEN / / RECONDITION /—/ DESTRUCTION /7" <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7,,5-1PIT PRIVY <br /> SEWAGE DISPOSAL FIELD W-F CESSPOOL/SEEPAGE PIT OTHER 3 F� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL } <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - _ Industrial Cable Tool Dia, of Well Excavation " <br /> Domestic/private Drilled Dia, of Well Casing S' =�/-� <br /> Domestic/public Driven Gauge of Casing %6e!U/1"Pi <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _�/ Rotary Type of Grout Pn ( a \ <br /> _Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> +.OMP .REPAIR: / / State Work Done <br /> :STRUCTION OF WELL: Well Diameter `J £'N Approximate Depth <br /> Describe Mate al and rocedure <br /> O <br /> T hereby agree to aws ann s r ct <br /> nd 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 .well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,-RIOR TO G OUTING•AN A INAL IAPF-CYION. ® <br /> SIGNED TITLEC%CIt lCe 1 �iirA d�� <br /> D PIs PLAN ON ffiRSE SIDE)T— ' O <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY U ' ��G ✓ DATE jr-_2V-)(e <br /> ,DDITIONAL COMMENTS: <br /> PHASE II VaOW INSPECTIOT PHASE III-/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .iUllllG Gftsooe <br /> � 3/76 2M <br /> E H 1426 R v. T- 4 <br />