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- _— <br /> •• SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBrOFFICE USE: 16011. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> i° : APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 763,?6 4J <br /> i 1,,;J_THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-1,7-,7 <br /> . (Complete 1n Triplicate) <br /> Application is .hereby pAde 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 the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner P s Name �,� U//�, Phone <br /> Address., _.. :,. �',:r City <br /> Contractors Name /SCS_ S te . ri g��li - :.- -License. hone <br /> i_ - _ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /'7 REC6NDITION•/_7 DESTRUCTION �]• <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK/jj! SEWER LINES,DD' PIT PRIVY 40 p <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 A Cable Tool Dia. of Well Excavation �. <br /> ,,`:Domestic/private• Drilled Dia. of Well Casing p <br /> Domestic/public Driven Gauge of Casing / <br /> ;Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ri <br /> Geophysical 4 Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP `.REPAIR: : <br /> J2ES TRUCTION 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 j <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 INSPECT <br /> PRIOR TO GROUTING AND A FIIJAI INS ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GMff 1. INSPECTIW . 0, irPHASE III FINAL INSPECTIO / <br /> INSPECTION BY DATE INSPECTION BY C.'' DATE G <br /> `3 E H 1426 Rev. 1-74 1-74 2M <br />