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onr, SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> rvr, ,OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 123 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION Q®� -- d` acs CENSUS TRACT <br /> Owner's Name' Phone Z <br /> Address p City ��, „L�-. <br /> Contractor's Name License Phoneme <br /> TYPE OZ-.WORK-(Check).: NEW WELL /,VI DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> + PUMP INSTALLATION /. PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /,,,3 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /(y <br /> X_ Domestic/private _.. Drilled Dia. of Well Casing �3<I <br /> Domestic/public Driven Gauge of Casing ��� s /,C 0 <br /> { Irrigation Gravel Pack Depth of Grout Seal llr-29 e <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal '• Other' Other Information y <br /> Geophysical, a Surface Seal Installed B !p <br /> PUMP INSTALLATION: Contractor `� r,L Z-.� <br /> F Type of Pump -c�5 / zs� /gyp H.P. - <br /> _ <br /> PUMP REPLACEMENT / / State Work Done ' <br /> PUMP .REPAIR: / / State-Work-=Done <br /> ' DES•TRUCTION 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 Calif ornia-pe-r-tainingto-orregnl.a-t-ing well.-;cons-tructi-on 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 RE;999Qf <br /> before putting the well in .use. The above <br /> information is tand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN <br /> SIGNED TITLE <br /> k70RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> w�HASE I <br /> APPLICATION ACCEPTED BY DATE 7, <br /> r ADDITIONAL COMMENTS: _T— <br /> ` PHAS ,, TRI GROUT INSPECTION P SE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> P <br /> ` E_ H 1426 Rev. 1-74 ~� _ f?7. 2NI_._. — <br />