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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F7) <br /> fT <br /> h �� t �- ._ (Complete In Triplicate) �?-?—cerO -[ <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 Joaquin4 <br /> County Ordinance No. 18/62 and the Rules, jand Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION�Q !� �-- <br /> 1. t re- CENSUS TRACT Q� <br /> Owner's Name „ G lL� Phone <br /> Address p P 04 A!f City <br /> D <br /> Contractor's Name &' A*0 AA <br /> License # 72-x' Phone <br /> k <br /> TYPE .OF,WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> -PUMP INSTALLATION 'X PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST:. .SEPTIC TANKF. . SEWER LINES PIT ,PRIVY D~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PR6PERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation <br />.�.���?�grne t :cjprivate_ �i}r fled Dia. of Well Casin • <br /> h � � S - lo ' <br /> _ ... _ _-sw...�- �- <br /> r��_ <br /> Domestic/public Driven Gauge of Casing `= <br /> --1L= Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection O_ Rotary Type of Grout +� <br /> Disposal Other Other Information ; <br /> Geophysical ;� Surface Seal Installed By: <br /> .PUMP INSTALLATION: Contractor w <br /> Type' of Pump H.P. } <br /> PUMP REPLACEMENT: [11 State Work Done <br /> PUMP .REPAIR: /i / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter kpproximate Depth`- <br /> Describe Material and Procedure <br /> I hereby agree ,to comply�writh 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 TO GROUTING AND ANAL. INSPECTIQN. r <br /> SIGNED_ - cs- TITLE 04U71 er <br /> 'r, DRAW I't T PLAN 'ON RE FRSE SIDE) <br /> 0 OR DEPARTMENT USE ONLY <br /> PHASE I F t <br /> APPLICATION A PTED B VA Lr N DATE / - 7-0-7,Z <br /> ADDITIONAL COMMENTS: � <br /> 9 PHASE II GROUT INSPECTION, WP I FINAL INSPECTI NINSPECTION BY • 11 DATE INSPCION DAT; 441-72 <br /> I' <br /> E H 1426 Rev. '1-74 ,° ` 376 <br /> ' _ <br />