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SAN,,JOAQUIN LOCAL HEALTH DISTRICT. <br /> r0i rOFFICE USE: 1601 .E. .Hazelton Ave. , Stockton, Calif. <br /> :one <br /> h <br /> Tele <br /> p � (209) 466-6 781 <br /> APPLICATION FOR WELL CONSTRUCTIR PUMP PERMIT Permit No. 75'-,5-4),J0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /mss <br /> . ftComplete In Triplicate) u r <br /> Application is hereby madetothe San Joaquin Local Health. District for a permit to construct y <br /> ° and/or install the-work herein described. This application-is made In compliance with San Joaquin <br /> f; County Ordinance No. 1862 and. the.Rules and, Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION '32,672 AL Lonre_ Xza, _ CENSUS TRACT <br /> ] I <br /> Owner 's Name fil Y_ L t �!/�. /I r ,n Phone d'/O S` <br /> Address --: .ssr ., .. M City <br />.1M 1 <br /> VPontractor'a Name License # Phone <br /> I <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN 4 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION L7 PUMP REPAIR /_7PUMP REPLACEMENT /_7 <br /> i Other <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <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 . r <br /> Irrigation Gravel Pack F Depth of Grout Seal <br /> Cathodic Protection Rotary F Type of Grout �.� <br /> Disposal _ Other I. Other Information i <br /> ' Geophysical. . Surface Seal. Installed BY: <br /> PUMP INSTALLATION.-a -, `-Contractor r <br /> Type of Pump ; H*P# <br /> PUMP REPLACEMENT: � y <br /> State'Work Done , ,I <br /> -PUMP REPAIR: L7 State Work Done Sea� k k/1 r n , use o wr Cr�i►-�: , <br /> pES.TRUCTION OF WELL: Well Diameter Approximate Depth 4 <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all lawns 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-fi'rnish the San Joaquin Local Health District a <br /> WELL DRILLERS'REPORT of the well and notify them_'�efore 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 INSPECTION <br /> PRIOR TOG TIN AND AFINAL INSPECTION. <br /> SIGNED TITLE <br /> t -DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; ` fj <br /> APPLICATION ACCEPTED BYDATE 6� "�S—_ <br /> ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPtCTION PHAS III FI AL 1NSPECTIO <br /> INSPECTION BY -> DATE INSPECTION BY DATE 77 <br /> 1 E H 1426 Rev. 1-74 174 2M <br />