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IleSAN JOAQUICAL HEALTH DISTRICT <br /> FOF ;OFFICE USE: -,1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL_CONSTRUCTION OR PUMP PERMIT Permit No. 733ZW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 6-/-76 ' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Lata, health Districtfor 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/LOCATION1e�g (,? -_- .r CENSUS TRACT <br /> Owner's Name ^.�LJIPN Arl: ./,..,, .,.- Phone ' Y,-3 j9 <br /> Address. g = Citp" <br /> Contractora Name License Phone <br /> TYPE OF WORK (Check).- NEW WELL /7T DEEPEN /- RECONDITION f? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 q <br /> Industrial Cable Tool Dia. of.Well Excavation ' hl <br /> Domestic/private . Drilled Dia. of Well Casing _ /�"1�t*� <br /> Domestic/public Driven`- Gauge of-Casing j <br /> Irrigation Gravel Pack Depth of Grout 'Seal R <br /> Cathodic Protection Rotary - Type of Grout ' &L1U <br /> Disposal Other Other Information c� <br /> Geophysics] Surface Seal Installed 'B� i <br /> I` PUMP INSTALLATION: .` Contractor <br /> Type .of Pump A.P. . <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 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 /> i,PRIOR TO GR UTING 'ANDA RNAL INWECTION. <br /> SIGNED WtieArTITLE <br /> (DRA PLOT PLAN ON REV RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE.h <br /> APPLICATION ACCEPTED BY fY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE•II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> :INSPECTION BY DATEj / NSPECTION BY DATE <br /> E H 3426Rev. <br /> c���-7� - h/-75 .2M- <br /> 1-74 - - -- _-- <br />