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i /x��� ��. <br /> � s c <br /> SAN- JOAQUIN LOCAL HEALTH DISTRICT d�U ,cc e a <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 6e *•�F -� ��-� r <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 -S/�;' <br /> THIS PERMIT EXPIRES 1,YEAR FROM DATE ISSUED Date Issued/ ZB <br /> (Complete :In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> t� L <br /> JOB ADDRESS/LOCATION • 0,0 CENSUS TRACT <br /> s Owner's Name ' Phone -- <br /> Address R . _ City <br /> Contractors Name License 117A.Aj3'hon( <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONI}ITION /_/ DESTRUCTION /�T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other: <br /> DISTANCE TO NEAREST: SEPTIC` TANK12 - <br /> SEWER LINES a PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC_ -DOMESTIC WELL,--.,---� <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ 1 Cable Tool' Dia. of Well Excavation 77 <br /> Domestic/privateDrilled Dia. of Well Casing <br /> S Domestic/public I Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal �- <br /> Cathodic Protection I J Rotary Type of Grout � rD C?i, ,77- <br /> Disposal Other Other Information _- p <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r Type, of Pump _ <br /> H.P-. <br /> PUMP REPLACEMENT: / / 'State Work Done-.. <br /> d <br /> PUMP .REPAIR: / /_ State Work Done ..�_ �_v�,- -- - <br /> DES-TRUCTION OF WELL: Well Diameter '.,R- ..y 6 .Q- O - Appzoximate 3�epth <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 ''pertainirrg to/or ;regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work ona new well, I will furnish the San Joaquin Local Health District a <br /> WE3L 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 'WILi; CALL FORA GROUT INSPECTION <br /> I PRIQR TO ,GROUTING 'AND A FINAL INSPECTION. <br /> !. SIGNED Py` - A TITLE-.-- <br /> (DRAW--SLOT PLAN ON REVERSE SIE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i - h <br /> Q . <br /> APPLICATION ACCEPTED BY ��� .i- DATE <br /> ADDITIONAL COMMENTS: -' <br /> PHAS I GRO T INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY40 DATE 2(a Ala INSPECTION BYb/77 2M <br /> E H 1426 Rev. 11,74 _ �:_--- <br />