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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx.OFFICE USE: -#f��1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-Za lid <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --S-7G <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION N l.�,I d CENSUS TRACT 2-oe-M'a•-21 <br /> Owner's Name Phone <br /> Address City ! <br /> Contractor's Nameill 14 License # Phone `'j ,�A <br /> TYPE OF WORK (Check): NEW WELL.'/ DEEPEN '/7 RECONDITION /7 DESTRUCTION <br /> PUMP INST TION / / PUMP REPAIR -/-7—PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 2---"Domestic/private Tom- rilled Dia. of Well Casing ^' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,3 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .,. ....`_.--- <br /> Geophysical Surface Seal Installed BY: -. <br /> PUMP INSTALLATION: # <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done I <br /> PUMP712EPAIR: State Work Done <br /> IIES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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.knowledge and belief. I WILL CALL FOR A GR NSPECTION <br /> PRIOR G UTING AND A NAL INSP XO <br /> SIGNED <br /> DRAW T P ON REVER SIDE <br /> DEPARTMENT USL ONLX <br /> PHASE I <br /> APPLICATION ACCEPTED BYdW DATE <br /> ADDITIONAL COMMENTS: 7i <br /> PHA II UT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �{�•r�, % ��lG�rdl � <br /> � ' r � L/75 2M _v' <br />