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SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:-- (-209), 466-6781 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L.JcL4_1, <br /> j 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 /> grid/or install the work herein described. This application is made in compliance with San Joaquin <br /> i County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> ti JOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name l _ 77_ d <br /> Phone <br /> Address City d„!1 <br /> Contractor's Name License•l2one�� -,Za <br /> TYPE OF WORK (Check): ' NEW WELL /7r-DEEPEN -/-7 RECONDITION /_7DESTRUCTION f7 = <br /> j PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT17 <br /> Other / / -- <br /> F DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE iDISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER { J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE -TYPEF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation, <br /> fes-Domestic/private' Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing �� w <br /> Irrigation. I + Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> ` - _ Surface=Seal;Installed 'B . <br /> ' ;\s,� X>% <br /> .PUMP INSTALLATION: —.Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT':' •. '.t/_/ State Work Done ” <br /> PUMP .REPAIR: / 7l > State Work Done <br /> 7 <br /> DE&TRUCTION' OF WELL: W611-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 <br /> ..REPORT well and notify them before putting.the..well. in.use.... .The above <br /> i. information is true to the•best� of- my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING'` U-A'7FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> --PHASE II.-GROUT INSP$CTION -- - -PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE S`=eC -7 7 T INSPECTION BY, DATE y. .2 /� 7 <br /> E :H 1426' a. Rev. 1-74' r 1./7K 9M r <br />