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w; SAN JOAQUIN LOCAL HEALTH DIS'­ytT <br /> FOT:OFFICE USE. ,` •01 E. Hazelton Ave. ,))Stockton Iif. <br /> Telephone: (209) 466-6781. <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. R <br /> { THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued LQ i6-2 <br /> ' Application is hereby mode (complete in Triplicate) <br /> ` Y to the San Joaquin Local Health District for a permit to construct <br /> 1 and/or install the work herein described. This application is made in compliance with San Joaqu <br /> County Ordinance No. 1862 and the" Rules' and Regulations of the San -Joaquin Local Health District <br /> JOS ADDRESS/LOCATION 7417 Al <br /> CErlsus TRACT <br /> Owner's Name `` <br /> /e_ r Phone <br /> 1 Address <br /> i <br /> Contractor's Name �,• <br /> 1' P ne <br /> F <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN "/? RECONDITION 1-7 DESTRUCTION <br /> PUMP INST9LATION / p OtherL_7 UMP REPAIR :/`] PUMP REPLACEMENT J T <br /> DISTANCE TO NEAREST: SEPTYC TANK <br /> S S �� PIT PRIVY <br /> SEWAGE DISPOSA�L�IELD� CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE fib PRIVATE STIC WELL" PUBLIC DOMESTI OTR <br /> INTENDED USE TYPE OF WELL LL <br /> Industrial Cable Tool {� CONSTRUCTION SPECIpICATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic/public Drilled bia. -Of Well Casing <br /> /public Driven <br /> Irrigation Gravel Pack Gauge of Casing <br /> �._ Cathodic Protection Depth of Grout Seal <br /> -Disposal - -,� Rotary Type of Grout <br /> Geophysical Other Other Information ' <br /> Surface Seal Installed 8 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump C CMZ <br /> _ <br /> PUMP REPLACEMENT / / State Work Done <br /> ' I <br /> PUMP :REPAIR: <br /> /? State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree Co comply with all laws and regulations of the San Jos ui <br /> and the State of California pertaining to or regulating well -construct n Local Health District <br /> after completion of ion. Within FIFTEEN DAYS <br /> mo 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..we11 in use.. � <br /> information is true to the-best.of' knowledge and belief. I WILL CALL FOR A GRp SNS above <br /> 'RIOR TO GROUTING D A INAL INS knowledge <br /> f PE I <br /> SIGNED v Q� <br /> TITLE 14 <br /> DRAW PLOT PLAN ON REVERSE SID { <br /> !RASE I FOR DEPARTMENT USE ONLY <br /> ►PPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: e;? 441DATE D <br /> PHASE II ROUT INSP IO <br /> NSPECTION BY DATA PHASE I INAL INSPECTIO <br /> NSPECTION $Y DATE <br /> i � 7 f <br /> E H 1426 Rev. 1-74Ji. <br /> i; s <br /> `. a <br />