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Ca ,L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh:OFF CE USE. 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> r Telephone: . (209) 466-6781 ` <br /> APPLICATION FOR WELL.CONSTRUCTIOW OR-PUMP PERMIT Permit No. 7S--�aeVP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6': 3-7J- <br /> (Complete In Triplicate) A�) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> k and/or install the work herein described. This application is made in compliance with San Joaquin <br /> t Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION - CENSUS TRACT <br />� . <br />�r Owner's Name a rc G p Phone <br /> t Address G e,c _ City QIM r <br /> Contractor's Name . License # lLr3Zhone - ,e <br /> 24 <br /> TYPE OF WORK (Check): NEW-WELL /7 DEEPEN ,/_7 RECONDITION /-7 DESTRUCTION f_7 <br /> PUMP INSTALLATION "/ 7 PUMP REPAIR REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELDCESSPOOL{SEEPAGE PIT OTHER T`` <br /> PROPERTY LINE �- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> -..—_ Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing € <br /> Domestic/public .Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal # ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , - <br /> Geophysical — - Surface Seal Ins tal-1 d"Ef <br /> f PUMP INSTALLATION: - <br /> Contractor <br /> Type .of Pump . H.P. V- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / <br /> State Work Done _ cid lir G Z no)�ra401,...+ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth' <br /> Describe Material 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, 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 tothe.be my..knowledge.; N <br /> .an.d-- belief. I WILL CALL FORA GROUT INSPECTIO <br /> PRIOR TQ UTING D A F. SPE T <br /> SIGNED T <br /> (DRAW PLOT PLAN O VERS. E <br /> FOR DEPARTMENTUSE 0 w <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z DATE -g-75 <br /> ADDITIONAL COMMENTS: E <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION By DATE ��` <br /> .T ION BY DATE `7S <br /> H1426 -Rev. 1-74 h/75 ° 2M <br />