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SAN JOAQUIN LOGAL-- EALTH DISTRICT <br /> FOAiOFF . .1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 31ee <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 8-7 <br /> (Complete In Triplicate) <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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f g7- 446v-ay <br /> iJOB ADDRESS/LOCATION i CENSUS TRACT <br /> Owner°s Name Phone g_-?X- pe <br /> Address ~: City 1 �r � <br /> Contractor's Name License # � Phone. g-9,,' /off <br /> TYPE OF WORK (Check).-- NEW WELL /? -.-�- _ �-,_.�-•,�>-..�-� _ _._- ,..r._/r -T�... <br /> bEEPEN RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /7-pump REPLACEMENT � .� " <br /> 1 1 Other / M <br /> DISTANCE TO NEAREST: '-SEPTIC TANKS SEWER LINES 4�,o PIT PRIVY <br /> S6dAGE DISPOSAL PIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> } PROPERTY LINE - PRIVATE DOMESTIC WELLj; PUBLIC DOMESTIC WELT, <br /> INTENDED USE ; TYPE OF WELL "CONSTRUCTION SPECIFICATIONS <br /> Industrial `", ; I1i :Cable Tool Dia. of Well Excavation <br /> rm <br /> �boestic/private' sDrilled Dia. of Well Casing / /v- .� <br /> Doma'stic/public Driven Gauge of Casing <br /> Irrigation g g ' i��,_4, <br /> E ,Gravel Pack Depth of Grout. Seal. i <br /> ti. Cathodic Protection a Rotary' Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ISurface Seal• Installed BY: <br /> 'UMP INSTALLATION: A- -Contractor <br /> Type Rof• Pumps ..,, -. H.P. <br /> PUMP REPLACEMENT: � [ State,Work Donee: <br /> .-PUMP-RFPAIR:-- ,- L'"T-.State Work Done <br /> ES�TRUCTION OF WELL: Well Diameter : Approximate Depth ' <br /> Describe Material and Procedure <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 regulat,in"well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Heal.tt 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED TITLE <br /> I DRAW PLOT PLAN ON REVERSE SIDE <br /> y FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE Z_ -' <br /> ADDITIONAL COMMENTS: <br /> t PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DAT / - 7� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ` <br /> r:- 1-742M <br />