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r . ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> X1. .1OFFICE USE: 1601 E. hazelton Ave. , Stockton, Calif. <br /> Teiephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-_Y44a J, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> {Complete In Triplicate) I� <br /> Application is hereby made -to the San Joaquin Local health District for a pea-mit to construct <br />,:p and/or install the work herein .described. This application is made in compliance with Sam Joaquin ] <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' ' <br /> .JOB ADDRESS/LOCATION �a� D :' <br /> CENSUS TRACT <br /> •Owner's Name Ji;Mf-,5 A100 Phone y7ol-' � p <br /> Address f� �'�1 Nb d� Cit <br /> Contractor's Name f/ <br /> _ License # Phone <br /> HYPE OF WORK {Check}; NEW WELL /�EEPEN 17 RECONDITION / 7 DESTRUCTION; / <br /> PUMP INSTALLATION UIP REPAIR /-7 PUMP REPLACMMIff- /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES foo - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER...„ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL.' PUBLIC DOME STIC"WELL ' • ^ti O' <br /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 0mestic/private Drilled Dia. of Well Casing <br />--�--Domestic%public, , --,,-Driven-�-�-R---=I -Gauge -of-Casing <br /> =Irrigation �✓Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> SurfacefSeal�IrisCalled BY: ;DjCrl.t, <br /> PUMP INSTALLATION: Contractor /�11 <br /> Type of Pump <br /> H.P. S' <br /> `PUMP REPLACEMENT:.-....... �. <br /> /_/ State Work Done • <br /> PUMP 'REPAIR: -7State Work Done . , <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and-Procedure <br /> � f 1 <br /> I hereby agree to comply with all laws-aud,regulatioies of the San Joaquin Local Health District <br /> and the State of California pertaining tokor;regulat'-ing;well construction. Within FIFTEEN DAYS , <br /> after completion of my woik on a new well,,;I Ta►ill_furnishthe San Joaquin Local Health District a + <br /> WELL, DRILLERS REPORT of the well and notiiy.them before putting-the- well in.use.. The above <br /> information is true to the•best of my -knowledge.4and belief. I WILL CALL FOR A GROUT INSPECTION w <br /> PRIOR TO GROUTING AND A FINAL INSPECTION', <br /> SIGNED TITLE t 1Xi <br /> `'' 1 , .DRAW PLOT PLAN ON--REVERSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br />.APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA IIINSPECTION PHASE FINAL INSPECTION <br /> INSPNCTION BY ATEZZ9VKSPECTION BY DATE <br /> E H 3426 • Rev. 1-74 <br /> 1-74 2M ► <br />