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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 4b6-6 8-1 -7 S- � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;;, ocel <br /> THIS PERMIT EXPIRES 1 YEAR,PROM ( •DATE ISSUED Date' issued 1-d-d-75� <br /> r <br /> (Complete In Triplicate) - <br /> I Application is hereby made to the San Joaquin Local.Health...District for a permit" tn construct <br /> and/or install the work herein described. This application...is -made.-in compliance with San Joaquin <br /> County Ordinance No. 62 and the Rules and Regulations of,the' San Joaquin,Local "Health District. <br /> JOB ADDRESS/LOC I 7 e. CENSUS TRACT <br /> Owner's Name Phone <br /> __z K_e4 <br /> Address / . .. City c. vim_ <br /> k <br /> { Contractor's Name License 4&_crZ,9 Phone66di� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ RECONDITION /7 DESTRUCTION f <br /> PUMP INSTALLATION �I ] PUMA',REPAIR ./� PUMP REPLACEMENT r <br /> Other / I <br /> r. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELL ' PUBLIC DONESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (,U <br /> Industrial Cable Tool Dia. of Well Excavation / C, <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven Gauge of. Casing <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 /> i <br /> PUMP INSTALLATION: Contractor �' s <br /> Type of Pump <br /> f . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PU14P :REPAIR: / 7- State Work Done - <br /> ES;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 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 Locat Health District <br /> WELL DRILLERS REPO o ° the well and notify them before putting. the.-well in-use.. The above <br /> information is u�FIWN e st o y knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G SON <br /> SIGNED � � TIT <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT -USE ONLY <br /> PHASE I f' <br /> `'APPLICATION ACCEPTED BY -7_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I UT INSPEC ION MR IjVFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> - .._.. . .. . . . .. _ .. - , <br /> � t E 11�1426 Rev. 1-74 1.74 2M <br />