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1 <br /> x SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> jis PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ;L 7--- <br /> Application is hereby made io 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 Satz Joaquin <br /> County Ordinance No. 1862 and he Rules and Regulations of the Sa Joa <br /> =.T h OpEP •�c E d,,� T� yy 9 n, Local Health District. <br /> JOB ADDRESS/LOCATION. r1. -d,v i A41��.0Aj <br /> �': ' cgo�Nc S q-� ,t1�S 1i� v� <br /> Gr CENSUS TRACT 5_3v, <br /> Owner's Name 1 S <br /> Phone <br /> Address <br /> \ City <br /> Contractor'a Name <br /> ty o^� C-3^1 _ _ License #,.2 Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION�/_-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> t Other e <br /> DISTANCE TO NEAREST: \SEPTIC TANK "f <br /> SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6� <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL s <br /> Industrial CONSTRUCTION SPECIFICATIONS h <br /> Cable Tool Dia. of Well Excavation ' <br /> Domestic/private' r. i Drilled Dia, of Well Casing <br /> Domestic/public. ; <br /> �, f. .given Gauge of Casing <br /> Irrigation i _ Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary 9TFe ,of--•Grout 4, <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor .� . <br /> Type off Pump <br /> PUMP REP LACEMENFT; � � 1 _ '. _ H•P. 7 <br /> / / State Work Done <br /> Aa te orRbon�e <br /> } <br /> ,SES TRUCTION OF WELL: Well Diameter t <br /> Describe Material and Procedure -- Approximate Depth <br /> I hereby agree to comply wit hlall 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 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 GROUT <br /> PRIOR TO GROU INC AND FIN ,•INSPECTION. CALL FOA INSPECTION <br /> SIGNEDOF OF <br /> TITLE <br /> I. (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> OR DUA&mMENT USE ONLY <br /> APPLICATION ACCE <br /> ADDITIONAL COMMENTS: DATE, - 5 <br /> P S I GROUT INSPECTION P II AL INSPECTIO <br /> INSPECTION BY DATE — INSPE <br /> 5 E H 1426 Rev. 1-74 <br />