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SAN JOAQUIN LOCAL HEALTH DISTRICT �5 <br /> FOF O&FICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7b/!1-71 <br /> Iq 6 (Complete In Triplicate) <br /> Application is her 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �p, �� CurzZ�s2e.u � dcd ENSUS TRACT <br /> Owner's NamePhone <br /> Address W0 9 City <br /> 4. <br /> - _r <br /> Contractor's Name -CN License # 1 Phone? <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ' /77 , <br /> Other / / 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SOD �4SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL "FIELD :- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELLI&_! PUBLIC DOMESTIC .WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> U <br /> Industrial Cable Tool Dia. of .Well Excavation <br /> Domestic/private Drilled Dia. of Well...Casing <br /> Domestic/public Driven Gauge of Casing K-_�a <br /> Irrigation Gravel Pack Depth of Grout Seal •--� N <br /> Cathodic Protection ----- �•­Rotary- -7 Type- of-Grout <br /> Disposal Other Othe`rr;Informaton <br /> Geophysical s .� Y -...,—S urf-ac e.--S e-a-1-Installed-B <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wbrk -I.}one <br /> PUMP REPAIR: ~. a / J . State Work Done� <br /> i <br /> -TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> r <br /> ! <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 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 not' y them before putting. the. well -in use.. . The above <br /> information is truetothe st o my k wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U NG A FIN); <br /> SIGNED TITLE 1 <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PIL�SE IC <br /> f <br /> APPLICATION ACCEPTED BY DATE <br /> y� <br /> ADDITIONAL COMMENTS .7,? <br /> PHASE II GROUT INSPECTION PHASEIPI/FIUL INSPECTION <br /> INSPECTION BY DATE T1 A-- INSPECT T BY DATE �✓���--� <br /> -K-H_1426 Rev. • 1-74 v/77 _ 2M <br /> �- <br />