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C/ SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> F'OHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,s-- 03p <br /> 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 /> anti/or install the workherein 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 /> Cp' r t-(.2 C`o n° + - pr,0-n I <br /> JOB ADDRESS/LOCATION iyT w S&U RAACTT <br /> Owner's Name Phone �j �� .2 3 <br /> Address , 1 ..�' o -uo--�, -�,.. �-� City ."",PK <br /> Contractor's Name _-1fLicense Phone33(.. f <br /> P 6F_4_6R0 (Check): NEW WELL /7 DEEPEN -/-7 RECONDITION / N � <br /> AL _7 DESTRUCTION' /_7 <br /> / <br /> PUMP INSTLATION REPAIR_PUMP REPLACEMENT f f <br /> Other / / r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL , N <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal (� <br /> Cathodic Protection Rotary Type of Grout s <br /> Disposal , . ..1. Other Other Information - <br /> Geophysical Surface Seal Installed BX: o <br /> PUMP INSTALLATION: Contractor + <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done L <br />, PUMP :REPAIR:a _State. Work Done: <br /> PES:TRUCTION OF WELL: Well Diameter Approximate Depth i <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 /> PRIOR TO GRO G D A_FIW INSPECTION. <br /> SIGNED TITLE <br /> D PLAT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATEJdi`�� <br /> ADDITIONAL COMMENTS: <br /> PHASE IV GM ISP , ON PHASE I , ./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 DATE 6-2,& ?,1' <br /> k E H 1426 Rev. 1-74 1-74 <br />