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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I <br /> (Complete In Triplicate) <br /> Application is hereby 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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L 4 3'31 P_ L Aoy CENSUS TRACT <br /> rOwner's Name Ze I Phone <br /> Address Sa <br /> 0 City AC01i-t Ora <br /> Contractor's Name . License # Phone <br /> 3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /! <br /> Other f/ / <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER 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 . t CONSTRUCTION SPECIFICATIONS , <br /> Industrial f Cable Tool '7 Dia, of Well Excavation <br /> 47 <br /> Domestic/private Drilled °, Dia, of Well Casing <br /> Domestic/public <br /> Driven ; Gauge of- Casing.4.�_ ._-._„ . <br /> +Irrigation Gravel -Pack - Depth of Grout Seal <br /> _ .. .. _. . <br /> Cathodic Protection Rotary Type of Grout ' ' r <br /> Disposal �.Other <br /> Other Information <br /> o motion <br /> Geophysical / <br /> -Surface Seal Installed ll a B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump `" �* ,., v H.P. <br /> PUMP REPLACEMENT• ;�' <br /> State Work Done ,l <br /> PUMP -.REPAIR: State Work Done Adel g2ta-e . <br /> 1 <br /> DES.iRUCTION OF WELL: Well Diameter a+► _ ,_ Approximate Depth <br /> Describe Material and Procedure- ­­ <br /> I <br /> rocedure 'I hereby agree to comply withfall laws and regu'lations '.o_f. the San Joaquin_ Local Health District <br /> and the State of California pertaining to or-regulat pini g well �'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wel{l,i I-willifurn sh. ltte San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify- them-before-putting=the-rwe1.l—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 w TITLE, <br /> { (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J-d -1 Z <br /> ADDITIONAL COMMENTS: 1 _...._._ <br /> PHASE II GROUT INSPECTION PHAS- TdI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / % ^° DATE 7 <br /> E H 1426 Rev. 1-74 11177 2M <br />