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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> ' FOR-OFFIGE USE,- * 1601 E. Hazelton Ave. , :Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � r <br /> y�G 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 Health Distr�ct.- <br /> JOB ADDRESS/LOCATION, - } k-Zqc-. J CENSUS TRACT <br /> I _ <br /> Owner's Name c� L2 Phone ' <br /> Address <br /> City <br /> Contractor's Name P, License # Phone <br /> TYPE OF WORK (Check): Q NEW WELL jw�DEEPEN-07_+RECONDITION!/'7 _DESTRUCTION .f-7 . <br /> ! PUMP INSTALLATION / / PUMP REPAIR E PUMP REPLACEMENT /-J <br /> Other l/ / <br /> DISTANCE TO NEAREST: SEPTIC�iTANK&/ SEWER LINES i PIT PRIVY <br /> SEWAGE.-DISP FIELDL CESSPOOL/SEEPAGE-PIT OTHER <br /> ' PROPERTY LINE - PRIVATE-DOMESTIC WELLX) " PUBLIC"DOMB$TIC WELL <br /> r INTENDED USE ..TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial I i Cable Tool . Dia. of Weil Excavation 1-19A 10/ <br /> Domestic/private. I Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation i � Gravel Pack Depth of Grout Seal <br /> p Cathodic Protection Rotary Type of Grout <br />` Disposal Other Other Information . <br /> Geophysical' Surface_ Seal Installed By: -- _ <br /> k P; INSTALLATION: Contractor 1�/N��- �'' - '" •• . .. - . <br /> jv Type ofPump�t�. fl;P. <br /> PUMP'REPLACEMENT:`. State Work(:Done � <br /> PUMP :REPAIR: %/. State�Work Done <br /> DES-TRUCTION OF WELL: Well Diameter �_ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin tocal Health District <br />` and the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> k after completion of my work on a new well, I will furnish 'the San Joaquin Local Health District a <br /> I WELL DRILLERS REPORT of the well and notify them before putting the..well in-use. The above <br /> information is true to the best of. my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GIJOUTING AND A F14ALIINS CT To'n. 12 <br /> SIGNED; _ Il TITLE <br /> (DRAW g . MAN Old <br /> 1 FQI� _D. , ART1I�fT_ MR-MIX- <br /> PHASE I <br /> -- — <br /> APPLICATI9N AOOE T B DATE7— ---Z2 <br /> ADDITIONA7, COMM8NT8; - _ <br /> -- - - - <br /> PHAS$ II GROUT. . 1SPECTI PHASE I N <br /> _ _ .. <br /> INSPECTION EY DATR INSPECTION HX DATA <br /> _. <br /> I E H 1426 Env_ 1'-74 ! '117T . 2m }. <br />