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. - <br /> 10 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. 7_.- S-uJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -T-,y� <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 41y �_- ,Q/j/� LJ� CENSUS TRACT <br /> Owner's Name <br /> Phone 3- 4 4 913Y _ <br /> '"rO�/ V/'4L � �X�.4 <br /> Address J7� �o (� � �- e/�- City e JnW 2Lq_, r7 <br /> Contractor's Name Ucense # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ,5-G SEWER LINESS'o 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 / I <br /> +Domestic/private 4--Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing — j7 - <br /> Irrigation Gravel Pack Depth of Grout Seal S"7 <br /> Cathodic Protection !/Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal e BY: <br /> r <br /> e'?PUIV INSTALLATION: Contractor <br /> Type of Pump rel H.P. <br /> PUMP REPLACEMENT: / / StateT . <br /> W(��-][ SCC <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well`'Leeter Approximate Depth <br /> Describe Material ank 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 to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRQWfUPG ANDA FIN SPECTION. <br /> S <br /> �GJD TITLE <br /> DRA D T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f7 /-72 <br /> ADDITIONAL COMMENTS: <br /> PHAS&jk GROUT INSPECTION PHASE I /F INSPECTION <br /> INSPECTION BY DATE , — 7 INSPECTION B ATE <br /> 3/76 2M <br /> E x 1Z26 Rev <br /> . 1-74 <br /> -74 <br />