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rr � <br /> m SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-OT.OFFICE USE: V1 , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,15 -_11 ?W J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /p-7 7 <br /> V36 Af1 !2-0 (Complete In Triplicate) 2z-e- 030- � (� <br /> Application is hereby made to the San Joaquin Local Health District for 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 th Rules and Rust n of the San •Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION74- <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address City Azzw <br /> Contractor's Name License # Phone S,Z2%D3y <br /> TYPE OF WORK (Check)-. NEW WELL/�7 DEEPENj-7-7 RECONDITION f_7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR/-7 PUNP REPLACEMENT f7 <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK 4Q-- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL 'r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �� t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public -- -..-'�"-- <br /> Driven Gauge of Casing / L <br /> fes Irrigation ✓ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ✓ . Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Typeof Pump H.P. Al~ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: /7 State Work Done - <br /> DESTRUCTION 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 /> PRIOR TO WUTING AN A INAL IN ECTIO . <br /> SIGNED F' <br /> > ITLE <br /> (DRA LOT P ON REV E SIDE <br /> PRASE I <br /> OR DEPARTMENT USE ONLY ( ,` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT INSPECTION PHASE IIIHXNINSPECTON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - 4/75 2M - <br />