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SAN JOAQUIN LOCAL -HEALTH DISTRICT - -- { <br /> FOF�rOFFICE USE, 601 E. Hazelton Aver ;.Stockton Calif. <br /> U Telephone: , x(209) '466-678 . <br /> APPLICATION FOR WELL CONSTRVCTION -OR PUMP PERMIT Permit No. 711-,,2-71,10 <br /> THIS PERMIT EXPIRES I .YEAR 'FROM DATE ISSUED Date Issued 717 <br /> (Complete In T'riplic'ate) <br /> Application is hereby made to the San Joaquin Local Health Disttict for a permit to construct <br /> and/or„install- the_worlc 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. CENSUS TRACT <br /> t1., <br /> Owner's Name Phone338-77-30 <br /> Address _ <br /> �A Yn�. .. "_ - ._ City <br /> Contractor's Name LicensePhone $ tea” <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /_7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / XARE §77PUMP REPLACEMENT /_7 <br /> Other J6211LC Gun. <br /> DISTANCE TO NEAREST: SEPTIC TANK_.. SEWER:LINES PIT_PRIV_ <br /> Y <br /> s SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC-WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ' „ h} TYPE OF WELL `ti - CONSTRUCTION SPECIFICATIONS Q <br /> Industrial a Cable Tool - Dia. of Well Excavation <br /> Domestic/p'r'ivate Drilled :Dia. of We1l'Oaeing <br /> _Domestic/publics _ Driven ' --Gauge of Casing <br /> Ixrgaton �� GravefFack Depth of Grout Seal <br /> * <br /> Cathodic-PTI' Rotary Type of Grout , <br /> Disposal ' °'F,k ' Other` Other .Information .'_, <br /> Geophysical. *,� Surface Seal Install ed:B : <br /> PUMP INSTALLATION: Contractor ` <br /> Type of 'Pump <br /> PUMP REPLACEMENT_: ,,, ,/_/,_, State Work-Done.--1 <br /> PUMP .REPAIR: State Wok Done /r4)0 <br /> ZES:TRUCTION _OF WELL: Well Diameter Approximate Depth. .,I <br /> Describe Materia 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, '•I1,will_fur'' ish_th'e San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- 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 GRD ING AND FINAL INSPECTION. 4 f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �y - <br /> PHASE II 4ROUT INSPECTION PHAS I I/ _ INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY -' DATE <br /> 'i E H 1426 Rev. I-74 1-74 2M M <br />