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N JOAQUIN LOCAL HEALTH DISTRICT <br />. FO$rOFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. t <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ; 5-,3�4d <br /> THIS PERMIT EXPIRES. 1 YEAR PROM DATE ISSUED Date Issued Z`13~71 <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 /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> � 7 ��YJ7'�� 1 <br /> Owner°s Maine �i�, Phone <br /> Address / ., city.�cr.� <br /> 4 <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/7 RECONDITION / DESTRUCTION k7 <br /> PUMP INSTALLATION /� PUMP REPAIR /-7-PUMP-REPLACEMENT /=j-- -�- <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Aj <br /> SEWAGE DISPOSAL FIELD CESS OL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> - <br /> INTENDED USE TYPE OF WELL _ 1 '_4y�iCONSTRUCTION. SPECIFICATIONS r <br /> Industrial Cable ToolRx - Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> " Irrigation Gravel Pack Depthyof Grout Seal <br /> Cathodic Protection Rotary Type 'of--Grout---t k,-%t) <br /> ,_I <br /> Disposal ' __ Other Other Information; � <br /> Geophysical Surface Seal Installed By: <br /> 4 n 3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ { ,� H.P. <br /> PUMP REPLACEMENT: / / State Work Done ------- - % - <br /> PUMP .REPAIR: /7 State Work Done <br /> JES®RUCTION OF WELL: Well Diameter T Approximatp Depth <br /> Describe Material and Procedure Y <br /> E ' <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 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 GROUTINGA FINAL IN ECT ON. <br />` SIGN TITLE <br /> (DWT PLOT PLAN ON REVERSE SIDE <br /> FOR DEPALT119NT USE ONLY <br /> F PHASE I DATE -1 `)s <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Wv <br /> �. E H 1426 . Rev. 1-74 1-74 2M �. , <br />