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L SAN TOAQUIN LOCAL HEALTH DISTRICT M / j ^ f0 <br /> FOI OFFICE USE: 1601 B`sIazelton Ave. , Stockton, Calif <br /> I. 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 <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> G� <br /> OB ADDRESS/LOCATION al s704ele <br /> ^,', • 0111412 k0f l— CENSUS TRACT _ p <br /> wner's Name <br /> �/1��,LD� y ML/7A/D , '/ 41 �Fi� p� /Phone ����S7o � <br /> ddress e[ ,rl h �� M0�°► �C1Z /��, lClp�� LIF /766 City V <br /> ontractor's Name 57A1J 1 Lf/ru S t k " j% icense # _ Phone v, <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-T DESTRUCTION / 7 <br /> V-1- AL <br /> C.a PUMP INSTALLATION M PUMP REPAIR / / PUMP REPLACEMENT /7 C <br /> IVP _ � Other <br /> Il <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> _ Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor — <br /> Type of Pump H-P' (/,o <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> ,ESTRUCTION 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 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 <br /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND A XIN I PECTION. <br /> SIGNE w4zftTITLE` l3!l1YJQJr�__ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 7 <br /> i7/7 2M <br /> E H 1426 Rev. , 1-74 ' <br />