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SAN JOAQUIN LOCAL HEALTH DISTRICT ®� <br /> FOR.OFFICE USE: 1601 E. `Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. —0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued <br /> (Complete :In Triplicate) <br /> Application is hereby n6de 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 73o Re ib Es r A -1, A/I/F. r CENSUS TRACT <br /> .Owner's Name l? 6L i 1-.:v 'L C_ Phone , r17 l 3 S7 <br /> Address (9 'City <br /> Contractor's name'_ 4V/y)1 cH iNE !$B CPLA018 'CC? License #j73q 7.(F Phone q&2 0��� <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN '/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> ..other /% <br /> 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLL" 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 Gage of Casing Q <br /> Irrigation Gravel Pack ?L of Grout Seal <br /> Cathodic Protection Rotary y`pe of Grout <br /> DisposalOtherher Information . . <br /> ,y Geo h sical <br /> P Y ,.*"` Of <br /> Seal 'Installed Bv: <br /> pcgIf 4� ^�^ <br /> PUMP INSTALLATION: hirac.tor <br /> Type .of Pump �tSG3/YIC2��>.I4L - H.P. <br /> PUMP REPLACEMENT: .' <br /> . ��/ State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: . • Well Diameter 'Approximate Depth <br /> ` Describe Material and Procedure ter' <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. iii.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 INSPE ION. <br /> 3 SIGNEDTITLE <br /> k (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE.ONLY <br /> PRASE I <br /> APPLICATION' ACCEPTED BY `" DATE <br /> A3?DITI013AL COMMENTS: t . <br /> PHASE II GROUV INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY NA eAl DATE <br /> 1426 Rev. 1-74 \ ��' r ��� 4/75 - 2M <br />