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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , € FOR.OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A�-3t3/o <br /> THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued. I-ia-7G <br /> (Complete In Triplicate) p . <br /> Application is hereby Ode to the San Joaquin Local Health District for a permit to cohatruct <br /> and/or install the world herein described. This application is made in compliance with:,San Joaqui <br /> ' = County Ordinance No. 1862 and..the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6 ' ' CENSUS TRACT - <br /> y . <br /> }Owner's' Name Phone Q// j <br /> ,Address r„J CityrrJ <br /> 61 <br /> Contractor's me Na <br /> x ' J License-# O-:3.73- Phone-46., _4_ = <br /> r TYPE OF WORK (Check) .- INI EW •WELL /7 DEEPEN •/7 RECONDITION /'7 DESTRUCTION <br /> 1-7 <br /> • <br /> PUMP,INSTALLATION _0/ -PUMP REPAIR/_7 PUMP REPLACEMENT /_7 <br /> Other• /-7 <br /> II # <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <br /> '• PROPERTY 'LINE, -. PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL :i <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i___._ Drilled Dia. of Well Casing <br /> s 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 /> Surface eansta <br /> - <br /> Geophysical SfSl IlleBd ' <br /> i lid. <br /> .PUMP INSTALLATION:. Contractor . <br /> ITYPe%of Pump H.P. <br /> =PUMP REPLACEMENT: I / State .Work Done <br /> PUMP .REPAIR: � J �/�. J� State Work Done ' <br /> �C <br /> ! DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 41 hereby agree to--comply with all laws and regulations of the San-Joaquin Local Health�District <br /> land the State of Califoinia' 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-Anowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A'�F'INAL INSPECTION. <br /> SIGNED kTITLE All 24-011 <br /> N� DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY I, r DATE (-22--~� 7 <br /> ADDITIONAL COMMENTS: 4, <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY Ii: - DATE INSPECTION BY <br /> DATE <br /> C4 <br /> E H 1426 Rev. 1-74 Id7q 2M <br />