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I FOR-7 OFFICE USE: ' SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466--6781 60 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 -U � p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (Complete In Triplicate) Date Issued <br /> Application is hereby made 25.17 <br /> to the San Joaquin Local Health District for a <br /> r permit <br /> and/or install the work herein described. This application ismade in compiancliance with San Joaquin <br /> to construct <br /> County Ordinance No. 1862 and the Rules a d Regu <br /> lat ns of the an Joaquiv Local Health <br /> JOB ADDRESS/LOCATION 7d� (�. 7. District. <br /> _ L7 <br /> icaLU-1— CENSVS TRACT <br /> Owner's Name <br /> Phone <br /> Address � <br /> City <br /> Contractor's Name L <br /> 4 <br /> 26 License #2 phone <br /> TYPE OF WORK- (Check) ; NEW WELL DEEPEN _ <br /> / / RECONDITION / / DESTRUCTION /� <br /> ' PUMP INSTAL TION �.' PUMP REPAIR / / PUMP REPLACEMENT / <br /> r _ _Other -/, / -- 7 �c <br /> DISTANCE; TO NEAREST: SEPTIC TANK;"-;.,r.' i <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE-DOMESTIC WELL PUBLIC DOMESTICTHER <br /> WELL- <br /> ; INTENDED USE TYPE OF WELL. <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavations <br /> Domestic/private Drilled <br /> Domestic/public '=Dia.• .of Well-Casing (� <br /> Driven Gauge -of Casing <br /> Irrigation ^ Gravel Pack. <br /> Cathodic Protection Depth of Grout Seal <br /> Rotary out <br /> Grout _ i <br />—Disposal Other <br /> Geophysical . ., �ther'Tnformation <br /> Surface 'Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Tyre of rum <br /> pGl�/Y�— H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure ApproximateDepth <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 co�'ipletion of my work on a new well, I will furnish the San-Toaquin Local. Health-District a <br />.JELL DRILLERS REPORT of the well and notify them before putti.ng�tle'.we�l; in use. The above <br /> Lnformation is true to the best of. my knoand belief, I .WILLCALL FOR=A- GROUT INSPECTION <br />'RIOR TO :GRO N AND �FIN�s_____10N­---a�. t- N <br />>IGNED <br /> rl ,* <br /> t TITLE" � . _� . • �. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �---,- <br />'HASE I fOR DEPARTMENT USE ONLY <br />.PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE r <br /> ~�pHASE `hI tJT- SPECT . .... _ �...t ,,. . ., .w.__ ... _Y--- <br /> NSPECTION BY DATE 'S II /FINAL`INSPECTION <br /> 4 <br /> INSPECTION BY DATE - `. $' <br /> _.E H 1426 Rev. 1-74ZO { <br /> .7-7 <br />