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PA-� JOAQUIN LOCAL HEALTH !DISTRICT ¢ <br /> FOL OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> d V., <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 <br /> (Complete In Triplicate) <br /> i. <br /> Application is hereby made to 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 />` Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance Na. 1862 and the <br /> i <br /> JOB ADDRESS/LOCATION 11,SQO A/ /�` CENSUS TRACT <br /> 1 <br /> Z/O 41 <br /> Owner's Naive TORN S N Phone <br /> Address. .$-Q ,Z City /�� <br /> License �� y Phone "NIL� /. <br /> Contractor's Name 4z Q,4 <br /> �-- . <br /> i <br /> TYPE OF WORK (Check) : NEW WELLX DEEPEN/_/ RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION '. PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> r <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <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 �R <br /> Industrial Cable Tool Dia. of Well Excavation ` <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -yam Irrigation Gravel Pack Depth of Grout Seal 5-0 . <br /> Cathodic Protection xRotary Type of Grout C,Ei`'rF'/V 7- <br /> Disposal <br /> Disposal Other _ Other Information <br /> Geophysical Surface Seal Installed By: /Vailc <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump S <br /> PUMP REPLACEMENT: / / State Work Done <br /> ; ,.PUMP_.REPAIR•, State,Work..Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ,¢ Ii4. <br /> I hereby agree to comply with all laws and regu rations q the San Joaquin Local Health District <br /> ' and the State of California pertaining to or regulating b�rell'canstruction, Within FIFTEEN DAYS <br /> $ ll furnish the San Joaquin Local Health District a <br /> after completion of my work an a new well, I wi <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 /> PRIOR TO GRO TING AND FINAL INSPECTION. L <br /> SIGNED TITLE • <br /> DRAW -PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:NTS: <br /> PHASE II GROUT INSPECTION P E III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6&g/) o,-4-,A /77 <br /> ,do .f;iq-"p LO!E_ -7A-� x,76 <br /> E H 1426 Rev. 1-/4 �, /' o�' 7 _ ` <br />