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t• <br /> r :• ,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: v 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 Date Issued 1 � <br /> (Complete In Triplicate) , <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ind/or install the work herein described. This application isimade in compliance with San Joaqui <br /> 'ounty Ordinance No. 1862 and theCRules and Regulations of the San Joaquin Local Health District. <br /> LB ADDRESS/LOCATION ��lp 6O < ,fj/A/ 7/� CENSUS TRACT OZ <br /> rer's Name ���, rj, 64ONi fg �1iQ Phone - <br /> iddress &-6�1 , f' A-6A1444 '060/ .,1A&&Czlg.j:::� City <br /> �ntractor's Name Q�/rf� License # Phone <br /> �PE OF WORK (Check) : NEW WELL Y DEEPEN /% RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK Gtd SEWER LINES, PIT PRIVY OA/ <br /> SEWAGE DISPOSAL FIELD 4A2'4 CESSPOOL/SEEPAGE PIT � OTHER <br /> PROPERTY LINFICWRIVATE DOMESTIC WELIAW'PUBLIC DOMESTIC WELL NG- <br /> INTENDED USE TYPE-.PF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> p✓Domestic/private Drilled Dia, of Well Casing O <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: e <br /> INSTALLATION: Contractor <br /> Type of Pump Me H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> MP .REPAIR: / / State Work Done <br /> mjISTRUCTION OF WELL: Well Diameter �Q�JQ� Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 'd the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 3LL DRILLERS REPORT of the well and notify them before putting. the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO GROUT G AND FINAL INSPECTION. <br /> .GNED TITLE L`' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> SE I <br /> 'PLICATION ACCEPTEDBY o DATE jZ 9 <br /> �ITIONAL COMMENTS. 11 Zp p S <br /> PHASE II G OUT INSPECTION PHASE III/FINAL INSPECTI N <br /> ISPECTION BY DATE INSPECTION BY DATE \ <br /> C36 <br /> 1— <br /> \Aw —A- <br /> E H 1426 Rev. - 1-74 <br /> b/77 . 2M <br />