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too ( <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MF CE USE: 1601 E. Hazelton Ave. $ Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zEz j1< <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued z2zy____zS` <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 Sari Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> .i <br /> JOB ADDRESS/LOCATION go W7 r` G"� <br /> . � `. CENSUS TRACT - <br /> Owner's <br /> RACT .Owner's Name Trt ``a d i Cx.. Phone , <br /> Address a i a "a City <br /> Contractor's Name �, <br /> License `/� Phone .,� '� <br /> i <br /> TYPE OF WORM (Check): NEW WELL /7 DEEPEN/? RECONDITION /? DESTRUCTION /f <br /> PUMP INSTALLATION / t)MP REPAIR -/�� PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Industria}. CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> _ <br /> Domestic' /private3 Drilled Dia. of Well Casing <br /> �.. Domestic/public Driven Gauge of Casing <br /> Irrigation 1 . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ," Rotary Type of Grout <br /> Disposal ` Other <br /> . Other Information . ' <br /> Geophysical Surface Seal Installed B <br /> 4 <br /> PUMP INSTALLATION Contractor <br /> l pt, <br /> f Type .of Pump '� . <br /> H.P. <br /> PUMP REPLACEMENT: . % / State Work Done <br /> FUMP :REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ._ <br /> Describe Material.and Procedure _j <br /> Approximate Depot <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 's <br /> WELL DRILLERS REPORT of !the well and notify t ore putting the -well in.use.... .The above <br /> information is true to the best-of le gearnd belief. <br /> PRIOR I WILL CALL FOR A GROUT iNSPECTTON <br /> G OU ING AN FIN } <br />� SIGNE ADTITLE <br /> 4 D W P :PLAN ON ERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY , DATE ' <br />` ADDITIONAL COMMENTS _;�X/7/ - <br /> PHASE Ii GROUT INSPECTION- PHASE III FINAL INSPECTION11 <br /> INSPECTION BY DATE INSPECTION BY ZS' DATE <br /> k E H 1426 `{ <br /> Y - - <br /> Rev. .1-74,, 1,/4C <br />