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SAN JOAQUIN�LOCAL HEALTH. DISTRICT <br /> M <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 4.66--6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k � . <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t� 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 District. <br /> i. JOB ADDRESS/LOCATION ; - � ; PNSUS' TRACT <br /> Owner's Name -�9 �sGLe 1 (Ioneki <br /> Address / y7z.l Sohn City <br />! Contractor's Name. License # Phone <br /> e <br />. i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION 4_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other-1 / <br /> TSTANCE TO NEAREST: SEPTICjTANK _ 0,' SEWER LINES PIT PRIVY <br /> f <br /> SEWAGE DISPOSAL FIELD ho CESSPOOL/SEEPAGE PIT OTHER U)_-1I- qo' q <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL +U <br /> j { INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation /„ C <br /> Domestic/private Drilled Dia, of W611 Casing <br />` Domestic/public Driven Gauge of Casing <br /> - Trxi. anon•,.- �� <br /> Gravel Pack ..�. Depth. of Grout. Seal <br /> Cathodic Protection Rota --`` <br /> y Typa "of lGrout - - _ <br /> l Disposal �- Other Other Information , rte <br /> Geophysical <br /> Surface Seal Installed By:_ �� t <br /> 4Ty'MP INSTALLATION: Contractor <br /> Type of Pum <br /> YP P H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PU.MP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe teria and Procedu <br /> -1- hereby agree 'to comply with, all laws an re lations of the S Joaquin Local Health District <br /> and the State of California. pertaining to or regulating well 'construction. Within FIFTEEN DAYS i <br /> aIfter completion of my work oin a new well, I will furnish the San Joaquin Local Health District a ? <br /> WE'LL DRILLER$ 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 GRO TING AND A F ALJINS CTION, a <br /> SIGNED TITLE <br /> i DRA. L T' ANON REV E SIDE) " <br /> O EPARTMENT USE ONLY <br /> PHASE T00, <br /> APPLICATION ACCEPTED BY DA E <br /> ADDITIONAL COMMENTS: <br /> P I 'ROT INSPECT N ' PHA II/ N INSPECTIqN <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> H 1426 Rev. 1-74 1 � ," �. 3/76 2M <br />