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FPO OFFICE FTSE• SAN 30AQUTN LOCAL.HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> f <br /> " THIS PERMIT EXPIRES L IFAR FROM DATE ISSUED ? <br /> A (Complete In Triplicate) Date Isaued ,7- <br /> -r--2 7� <br /> pP UCdtion is .hereby made to the San Joaquin Local Health District for a permit to con <br /> and/or install. the work herein described. This application is made in compliance wit Strutt <br /> County Ordinance Na. 1862 anti the Rules and Regulations of the San Joaquin L h San Joaquin <br /> JOB ADDRESS/LOCATION <br /> g� q ocal Health District. i <br /> CENSUS TRACT <br /> Owner's Name `{ <br /> Phone <br /> Address ,, ". .l A:$ 71-; <br /> Contractor's Name City ' <br /> License <br /> V-79-00 Phone F <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /? RECONDITION 7 DESTRUCTION r =J=~ <br /> ;PUMP INSTALLATION / I PUMP REPAIR CTYON <br /> I <br /> f Other %f PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOS,A�L gY ,�R LINES PIT PRIVY f <br /> CESSPOOL/SEEPAGE. PTT OCH <br /> PROPERTYiLINE - PRIVATE DOMESTIC WELI:' <br /> TPUBLIC bOMESTIC WELL' <br /> INENDED USE TYPE OF WELL <br /> _._.Industrial -CONSTRUCTION SPECIFICATIONS.. b, <br /> 1` Domstic/private _ fE. Cable Drilled Tool Dia. of We" Excavation - � <br /> A- <br /> j Domestic Dia. of 'Well Casing °ice <br /> o -_ Driven, <br /> Gauge of Casing . <br /> .: Gravel Pack <br /> Cathodic- Protection Y - t Rotar` Depth of Grout Seal i <br /> _Disposal e y Type of Grout <br />—Geophysical � ' � ,Other ----�_ Other IZ1fD1°matiOn .: <br /> 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of .':Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> Ll State Work Done <br /> `— e WorFt DoneJ"�' <br /> � p -` "—'-mow ��.. �. �•,�.,��,„„ <br />)ESI RUCTIONOF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> C hereby agree to comp <br /> 1Y With all laws <br /> . and regc:lations of the San Joaquin Local Health District <br /> ind 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 /> TELL DRILLERS REPORT of the well and notify them before Putting-the- well in use.. The above , <br /> reformation is true to the-best, <br /> RIOR of my knowledge and belief. I WILL, CALL FO A GROUT INSPECTION <br /> TO GR UTING .AN A INAL INSPECTION.. <br /> IGNED I - <br /> TITLE <br /> DRAW PLOT PLAN ON- REVERSESIDE <br /> HA�SE I MR DEPARTMENT USE ONLY , <br /> PPLICATION ACCEPTED BY Q <br /> DDITIONAL COMMENTS: j DATE <br /> PHASE II GROUT INSPECTION <br /> NSPBCTION BY DATE PHASE TII INAL INSPECTION <br /> —. INSPECTION BY . !� — DATE l 2 y <br />.•" _ . a. <br /> E H 1426 Rev. 1-74 <br />