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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> #FO OFFICE USE: <br /> f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 •/�Sr�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued� _7G <br /> (Complete In Triplicate) <br /> A lication'is here y 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 0 dinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION P C !0i. Cc CENSUS TRACT <br /> Owners Name - WWA4 c �,e Phone 334/•-403r <br /> Address City CxI �_e-xool <br /> Contractor's Name _`?�1 �!. i �.=? c License #�Zalp3 Phone 247,23%!V <br /> TYPE OF WORK (Check): NEW WELL/� DEEPEN /7, RECONDITION /-T DESTRUCTION j <br /> PUMP INSTALLATION PUMP REPAIR 7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK fooSEWER 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 « N <br /> Domestic/private Drilled Dia. of Well Casing 6 s" <br /> Domestic/public Driven Gauge of Casing /;L <br /> Irrigation Gravel Pack Depth of Grout Seal 4"0 F `� <br /> Cathodic Protection 5_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor 2 6,5'7 w ° <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> PMP , .P R: /7 State Work Done �\ <br /> WgWell Diameter — proximate Deptht.f <br /> Describe Material and Procedure <br /> pI hermply with all laws and regulations of the San Jodquin L a1 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 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE <br /> DRAW P REVERSE SID <br /> Polk-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHAS " JI GR INSPECTION PHAS SPECTION <br /> INSPECTION BY ! - DATE 5` -7/ INSPECTION BY E <br /> E H 1426 Rev. 1-74h/75 9M <br />