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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FM OFFICE USE: l'/ 1601 E. Hazelton Ave. , Stockton, Calif. 11 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�f 1/fry W <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3-1--7v, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth 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. 1 <br /> sL16 6&1P/7 <br /> JOB ADDRESS/LOCATION y- -- CENSUS TRACT j <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name License # Phone - .3 <br /> �-:�S 4 <br /> TYPE OF WORK (Check): NEW WELL jj DEEPEN /T7 RECONDITION /_7 DESTRUCTION /_7 <br /> ' <br /> ,.- --PUMP -INSTALLATION, / /-, PUMP-REPAIR-/77~,PUMP REPLACEMENT <br /> i � <br /> DISTANCE TO NEAREST: .\ SEPTIC TANKSEWER LIN13S PIT PRIVY <br /> 0( SEWAGE DISP09AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> mINTENDED U5E[ ''l TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial e Cable Tool Dia. of Well Excavation <br /> ;.� Domestic/pri�ate- Drilled Dia. of Well Casing (�, � <br /> Domestic/public Driven Gauge of Casing TZIN ' <br /> Irrigation Gravel Pack Depth .ofmGrout Seal <br /> Cathodic Protection Rotary j Type o€ Groutmm <br /> Disposal Othert Other Information a ' <br /> Geophysical f Surface Seal Installed B :� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : I i <br /> H.P. W� <br /> PUMP REPLACEMENT: State Work Done NA g <br /> / / ,,,... ._.... _,_...:. <br /> PUMP IREPAIRIV) L-7 State Work Doe <br /> 1)ES-TRUCTION OF. WELL: Well Diameter r � �� r." � '� Approximate Depth r <br /> : Describe Materialland`Procedure 1N' <br /> I hereby agree to comply with all laws and.regulations `of the San Joaquin Local Health District <br /> and the State of i Californian pertaining to or, regulating` Fell construction. Within FIFTEEN DAYS ,'m <br /> after completion,,of my Vork- on a neva: well. I will,fb..rAiA 'the San Joaquin Local Health District a � <br /> WELL DRILLERS REPORT of the well and notifythem before 1 <br /> 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-.ANDA FINAL INSPECTION. I} TITLE <br /> SIGNED` <br /> + (DRAW PLOT PLAN ON REVERSE SIDELC <br /> r <br /> , FOR DEP NT USE ONLY <br /> PHASE I <br /> I r <br /> APPLICATION ACCEPTED BYi DATE -7 <br /> ADDITIONAL COMMENTSTIM : i <br /> - , OU - I Q„ I FINAL INSPECTION <br /> I <br /> INSPECTION--BY- �. I GROUT DATEINSP- <br /> fi _ INSPECTION-BY DATE <br /> '� - E H 1426. Rev, 1-74 rt 1-74 2M <br />