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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. ;26_sad 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date ,Issued -Z-,3e-26 <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 Joaquin <br /> County Ordinance No. -1862 a d the Rules andikegulatione .of, the San -Joaquin Local Health District.. <br /> JOB ADDRESS r. CENSUS TRAGI <br /> Owner's Name / <br /> Phoneme , <br /> Address City . . , <br /> Contractor's Name Q <br /> License 4 rphone f z/. <br /> t TYPE OF WORK (Check): NEW WELL`/ DEEPEN -/?. .RECONDITION /- .DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /? PUMP REPLACEMENT /_]" <br /> Other <br /> k - <br /> DISTANCE TO NEAREST: SEPTIC TANK R <br /> �� SEWER LINES Q PIT PRIVY . <br /> SEWAGE DISPOSAL ' -- C oot SEEPAGE PIT 1--OTHER <br /> PROPERTY LING VPRIVATE DOMESTIC-WELL"24 PUBLIC DOMESTIC WELLr -' <br /> INTENDED USE TYPE OF WELLg _ CONSTRUCTION SPECIFICATIONS <br /> a� Industrial Cable Tool Dia. of Well' Excavation <br /> Domestic/private Drilled max . Dia.eof�Well Casing <br /> Domestic/public Driven s ter. Gauge of, acing " <br /> ''Irrigation Gravel Pack Depth of 'Grout Seal <br /> CathodicProtecti`ari"' -�Rotary { '. Type of Grout :. . <br /> r Zia,fg:I : a <br /> *Disposal -Other , _ Other InforUation' <br /> Geophysical <br /> --Surf aceje7al Installed 'B : 2f . <br /> PUMP INSTALLATION �; Contractor1JN, - <br /> . <br /> Type <br /> _of Pump C. H.P. <br /> 4 <br /> PUMP REPLACEMENT: -m, Work Done - .•.`� ,.,� - - � <br /> j � State <br /> PUMP 'REPAIR:' / State Work Done ' <br /> OESiTRUCTION OF WELL: , ' Well Diameter <br /> Approximate Depth � <br /> 3 Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 /> 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-7n GROt1TING AND A FINAL INSPECTION. + <br /> 'SIGNED i <br /> i <br /> DRAVIPLOT PLAN )ON REVERSE SIDE f <br /> FOR DEPART T USE ONLY <br /> 'PHASE i <br /> :APPLICATION ACCEPTED BY :Z��; DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I'l GROUT .INSPECTION PHAS I F AL INSPEC <br /> ; xpiq <br /> INSPECTION BY; :. y DATE INSPECTION BY . leiDATE <br /> f <br /> Rev. 1-74 y r ►. a,� ., <br />