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Y <br /> 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. /13id <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complexe In' Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wori herein described. This application is trade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of 'he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ! ,3 J� --CEN US TRACT <br /> Owner P s Name �} Phone <br /> Address <br /> 63 f4 City <br /> Contractor s Name w, License # Phone <br /> I TYPE OF WORK (Check): NEW WELL DEEPEN`'/- PRECONDITION /-7 DESTRUCTION f-7 <br /> :;PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other /-7 } <br /> DISTANCE TO NEAREST: SEPTIC TANK SQ SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I 4OPERTY,LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Cl' <br /> INTENDED USE II TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable fool Dia. of Well-Excavation '- <br /> �_ Domestic/private', Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth- of Grout Seal <br /> Cathodic117/1 <br /> Protection �_ Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump B.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PU1+B:' !REPAIR: . .. r �/7= State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter ` C 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 Califo'rnia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion'of my rwork 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 TO GjROUTING AND-A! NAL INSPECTION. 619 <br /> SIGNED ITITLE <br /> �I. DRA LOT PLAN ON RS E SIDE <br /> FOR DEP MENT E ONLY <br /> PRASE I nn / <br /> APPLICATION ACCEPTED Dl `,4 4 O DATE T r 7 <br /> ADDITIONAL COMMENTS: I <br /> PHASkill. GROUT INSPECTION P S ' I FINAL INSPECTION <br /> INSPECTION BY °il. DATE - -'�s t INSPECTION BY DATE 6-6­76' <br /> 1 E H 1426 Rev. 1-74 '. 1-74 2M <br />