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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. 71 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -g:Z9 <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 Jo4quin <br /> County Ordinance No. 1862 an4 the Rules and Regulations of the San Joaquin Local Health District. { <br /> JOB ADDRESS/LOCATION 3 7 -7 �� <br /> Y � ���s CENSUS TRACT <br /> Owner's Name M �� �• R y <br /> e r Phone <br /> Address `j Cit r <br /> Y <br /> Contractor's Name a Licensel�� Phoney <br /> ~1.. -7 <br /> tl <br /> TYPE OF WORK (Check) : NEW WELL /ji?�DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 F. <br /> PUMP INSTALLATION`%;:�-'rPUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / --- <br /> DISTANCE TO NEAREST: SEPTIC TANK -o SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I I-- Cable Tool Dia, of Well Excavation 1101 <br /> Domestic/private"`' — <br /> /P Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing In <br /> V Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ri � <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: /� State Work Done Al`cz lu I 4L, <br /> PUMP '.REPAIR: / / State Work`Done <br />]ESjRUCTION OF WELL: Well Diameters Approximate Depth <br /> Describe Material and- Procedure <br /> Z hereby agree to comply with all lavas 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROU ING D A FINAL INSPECTION. <br /> iIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEk� �� <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> I <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY DATE i 2:- 7� <br /> E H 1426 Rev. 1-74 % 2M 1 <br />