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C`m SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) A?7_ 0-CO --1,P <br /> Application is hereby~rade to the `San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applicatioh.. is mac3.e in'n' compliance with San JoaquiPn <br /> ' an Joa ,in Local Health District. <br /> " County Ordinance No. 1862 ad -the Rules and Regulations of th u <br /> q <br /> S"7 2 5 ALJ o <br /> JOB ADDRESS/LOCATION �' UK/ � � ®�>� CENSUS TRACT <br /> Owner's NamePhone <br /> Address _ I city Jp _2s, _-- <br /> Name <br /> Contractor's f License �� _71��i Phone �-J156- -7624 <br /> I, TYPE OF WORK (Check) ; NEW WELL / DEEPEN /—% RECONDITION / / DESTRUCTION <br /> PUMP "INSTALALLA.TION / J PUMP REPAIR 141 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER [v <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 <br /> Domestic/private Drilled Dia. of 'Well Casing <br /> Domestic/public- Driven Gauge of Casing <br /> Irrigation _ Gravel .Pack -Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal Other Other Information <br /> i Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> .-..Type of Pump r H.P. <br /> PUMP REPLACEMENT-: ` . . <br /> ] / . State Work Done <br /> _ <br /> PUMP .REPAIR: /1C/ State Work Done o d G6 az) �Qi a <br /> I <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> 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 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. knowled nd belief. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPE IO <br /> SIGNS T - 'IYTLE <br /> !ZKDYAW PLOT PLAN ON FRSE SIDE) I. <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> F ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN CTION PHASE III/FINAL INSPECTION 7 <br /> INSPECTION BY DATE INSPECTION BY DATE 7T% /_ <br /> E Hf .1426 Rev. 1-74 - 7- 76 2M <br />