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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f0_R70FFICE USE: j,rJ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> RRA AP 'ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT V Permit No.� �7S3t.J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued 6 <br /> ...tom i —�- <br /> ?;f � `N.7Gr"c�� _:. {Complete In Triplicate) 00; =oen_:-17 ' <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 /> County Ordinance No, l 2 and the Rules and Regulations of the San -Joaqu n Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone �/7�,z.-.� <br /> Address R - city . <br /> Contractor's Name (,� ,� <br /> License #a O S' Phone <br /> t <br /> TYPE OF WORK (Check):' NEW WELL '/Z7-- DEEPEN /-7_RECONDITION f_7 DESTRUCTION /7 <br /> PUMP`ilo ALLATIQNDUMP REPAIR '/� PUMP REPLACEMENT /7 <br /> Other /:/ <br /> DISTANCE TO NEAREST: SEPTIC'r K. SEWER LINES PIT PRIVY s <br /> Alo ;S a rc 0,v 1SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> a-40 z <br /> LINE -- PAIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> MENDED USE f PE OF WELL s CONSTRUCTION SPECIFICATIONS <br /> Industrial LCable -Tool Dia. of Well Excavation. <br /> r/bomestic/private - Di-illed Dia. of Well Casing f� <br /> Domestic/public _.___r._. Driven I Gauge of Casing <br /> Irrigation - e -Gravel Pack I Depth of Grout Seal k / �} <br /> Cathodic Protection ;j£R7% tary Type of Grout <br /> Disposal w Other Other Information <br /> Geophysical <br /> .; . Surface Seal Installed 'B i <br /> ICI <br /> PUMP INSTALLATION.* � ConCractor <br /> { Type of Pump ? H.P. <br /> PUMP REPLACEMENT: . / IT State Work Done <br /> PUMP ,REPAIR: k <br /> State Works Done � - <br /> ...,� <br /> DESTRUCTION 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�o,rwregulaeing weell-construction-.-Within.-FIFTEEN_DAYS- ' <br /> after completion ofy work'--on a new well, I will furnish the San Joaquin Local Health District a i <br /> WELL DRILLERS REPORTof 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 />?RIOR TO GROUTIN D A INAL NSP CTION. <br /> SIGNED TITLE <br /> �i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I `-- <br /> APPLICATION ACCEPTED BY DATE ' ,A y <br /> ADDITIONAL COMMENTS: x, r <br /> PRASE 11 GROUT INSPECTIONP SE i I FIN INSPECTION- <br /> INSPECTION BY -DATE INSPECTION DATE <br /> 7. <br /> �f <br /> -e f <br /> E H 1426 Rev. 1-.74 f^ rf h_/75 2M . <br />