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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=67$1 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S--_®Zl1.2 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE-.'.ISSUED.` <br /> ' I (Complete In Triplicate),, s .A <br /> Application is her, made to the Salt Joaquin Local. Health District for ,.a­permit -to ,construct <br /> and/or install the work;�herein scribed. This application :is ..made;.,In-compliant with San'-Joaquin <br /> County Ordinance No. 1862 and he s a i Sa Jo q ealth.District. <br /> i�. <br /> JOB ADDRESS/LOCATION M / /�/f� ►. tQC(�ENSUS Q TRACT <br /> • F - s <br /> I� �� _ •. <br /> Owner P s Name Phone <br /> Address it 0 _ Y .-. _ w_. <br /> Ci ty <br /> Contractor's Name I o�c License me Phone <br /> TYPE OF WORK (Check) : NEW WELL .,& DEEPEN -/? RECONDITION /7 DESTRUCTION f7— � <br /> PUMP INSTALLATION � PUMP REPAIR, /_7 PUMP REPLACEMENT /—f,. .. f <br /> Ether / / <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 . <br /> - Industrial Cable Tool Dia. of Well Excavation Q �, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _11 <br /> Irrigation Gravel Pack Depth of Grout-Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other .Information .. <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ��c. <br /> Type of Pump1112 S.P. <br /> PUMP REPLACEMENT: /., / State Work Done <br /> PUMP .REPAIR: L7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 stork on a new well, I will furnish the .San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofj�the well and notify them before putting.the,.well in use. The above <br /> information is true to tihe-best of- my knowledge and belief. I'MILL CALF: FOR A GROUT .INSPECTION <br /> PRIOR TO GROUTING 0 <br /> SIGNED ��. a TITLE <br /> iM RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMF NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> P E74� - <br /> INSPECTIOPWf INAL INSPECTION <br /> INSPECTION BY DATE f APECTION BY ; = oe DATE = <br /> E H 1426 Rev. 1-74 1-74 2M <br />