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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&iOFFICE USE: 1601 E. Hazelton Ave. , Stockton',- Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 3 iQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM--DATE ISSUED Date Issued -,7-,Z;"- <br /> (Complete <br /> 7-75(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. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> &I_ �. 4 u <br /> JOB ADDRESS/LOCATION A L �SicLp, CdSIs ehe ''L.ge- CENSUS TRACT <br /> 4�g _ Soz 4a <br /> Owner's Name Phone, 5731 2 <br /> a� 1 �c.1 <br /> Address C J Q 1, P City 1 c- N..� <br /> Contractor's Name License # Phone qbb-'q WS- <br /> T LL____V <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN =T RECONDITION /7 DESTRUCTION f7PUMPijINSTALLATION PUMP REPAIR i-1 PUMP REPLACEMENT �. <br /> Other 1 I N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' C' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' - PUBLIC DOMESTIC WELL gm <br /> INTENDED USETYPE O WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I V Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> E2'Domestic/public Driven Gauge of Casing 112 <br /> Irrigation Gravel Pack Depth of Grout Seal ------- <br /> Cathodic Protection Rotary Type of Grout --�-� <br /> Disposal Other Other Information <br /> Geophysical � - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Tllk,Iclaz- <br /> ype of Pump e L. H.P. <br /> [� <br /> I PUMP REPLACEMENT: / / J State Work Done <br /> PUMP 'REPAIR: -iFState Work DoneF - <br /> ` it <br /> ,pES;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 Stat alifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after co etion o my wg4g <br /> ;naw well,. I will furnish the San Joaquin Local Health District a <br /> WELL DR LLERS REPO ofd notify them before putting the..well in-use. The above <br /> infor ation t e tomy knowledge and belief. I WILL L FORA GROUT INSPECTION <br /> PRIOR TO G -AND <br /> SIGNEk TITLE zyjg���� <br /> iM (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTME T USE ONLY <br /> PHASE I / 7 <br /> APPLICATION ACCEPTED BY DATE / > / <br /> ADDITIONAL COMMENTS: 7 <br /> t PHASE II GROUT INSPECTION PHAS /FIN INSPECTION <br /> INSPECTION BY i DATE INSPECTION B DATE - <br /> '1 ~E H 1426 Rev. 1-74 i 1-74 2M <br />