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n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFS'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 75-S49A4rJ <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z:A?•S- I <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 and the Rules and Regulations of the San Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION ,�7 CENSUS TRACT 4 r <br /> Owner's Name r Phone <br /> Address / 0 "• . 2 City - <br /> Contractor's <br /> ity Contractor's Name / U iP CG License # 1462 Phone tL4�­6�7 <br /> r <br /> TYPE OF WORK (Check): NEW WELL ,/ / DEEPEN ,FT RE_ CONDITION / DESTRUCTIOR-f—T . <br /> MP ST <br /> -- <br /> PUMP INALLATION PUMP REP _AIR /� PUMP REPLACEMENT /7 ' <br /> Other / / _ _ -. . . . I <br /> _4�' <br /> DISTANCE T0, NEAREST: SEPTIC TANK /00 SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool i Dia. of Well Excavation . <br /> Domestic/private Drilled Dia. o€_ 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 /> s Disposal Other Other Information " <br /> Geophysical « Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump-, H.P. <br /> F <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> T �IDES4RUCTION OF WELL: Well Diameter ' Approximate Depth ~ <br /> Describe Material and Procedure <br /> 1I hereby agree to comply with all laras -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 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 GROUTING AND A FINAL INSPECTION. <br /> SI ED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ( ADDITIONAL COMMENTS: <br /> 1 P E ROUT INSPECT N DISE IIT rINAL INSPECTION <br /> INSPECTION BY 77' DATE INSPECTION BY DATV,� ;�S1 <br /> 2M <br /> R R IL.26 Rp4-cy_ 1-7 r <br /> l . <br />