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E R FSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date IssuedvZS=js- , <br /> 'Application is hereby (Complete In Triplicate) <br /> eby made to the San Joaquin Local Health District for a permit to construct E <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. l <br /> ;l <br /> JOB ADDRESS/LOCATIONpy <br /> CENSUS TRACT <br /> Owner's Name .1 I-/n/% <br /> _ Phone <br /> Address <br /> � Cityn � <br /> Contractor's Name Al4 CH <br /> h License , Phane <br /> TYPE OF WORK (Check): NEW WELL Lam' DEEPEN /7 RECONDITION /7 DESTRUCTION i <br /> PUMP INSTALLATION Lv��PUMP REPAIR /? PUMP REPLACEMENT 1-7 ` <br /> Other L7 <br /> ob <br /> DISTANCE TO NEAREST: SEPTIC TANK Nat SEWER LINES inn f- PIT PRIVY <br /> I <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE���PRIVAT$ DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ICONSTRUCTION•SPECIFICATIONS <br /> = Industrial.' Cable Tool � Dia. of Well Excavation <br /> ,_�Domestic/pkrivate Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven`"� ;� Gauge of Casing } 1 <br /> Irrigation �� Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection s� btar r- - Type of Grout <br /> Disposal Other f G�md <br /> Die `y " %%. i <br /> P �� Other Information, -_i• <br /> Geophysical 1 Surface-Seal I�nssLtalled BY: Qit� i <br /> PUMP INSTALLATION: Contractor <br /> I� Type of Pump g- R-4-1 <br /> P. s-- <br /> PUMP REPLACEMENT: / / State Work Donee <br /> ?UMP :REPAIR: Ip /7 State Work Done v'f <br /> ES•TRUCTION OF ALL: Well Diameter l/ <br /> Approximate Depth 7U <br /> �j Describe Material and Procedure ; <br /> ,II <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 x <br /> if ter completionjFof 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> ;IGNED TITLE ,[��+ ; <br /> DRAW PLOT PLAN ON REVERSE SIDES { <br /> i FOR DEPARTMENT USE ONLY <br /> 'RASE I I 0 r <br /> xPPLICATION ACCEPTED BY {t/c�� DATE -z <br /> ADDITIONAL COMMENTS: <br /> PMMII OOUT INSFtCUON PHA II F N INSPECTION <br /> NSPECTION BY DATE _�d - INSPECTION BY TE <br /> E H 1426 Re' 1-74 1-74 2M <br />