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N SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt*;OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. " <br /> Telephone`: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _ THIS PERMIT EXPIRES l YEAR FROM ,DATE 'ISSULD Date Issued 1. -3-7� <br /> (Complete Irk Triplicate) nstg i�G <br /> Application is hereby made to the San Joaquin Local rtlealth, :District for .a permit to consttct <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, Joaqu oval. Health Dis rict. <br /> JOB ADORES /�d I IF- :.:�S 1 12-CENSUS, CT <br /> / t. � � <br /> Owner's Name � . Phare . <br /> Address 7: Clay , <br /> / aa <br /> Contractor's Name ..� License,. 74?4hone <br /> TYPE OF WORK' (Check) : NEW WELL/ DEEPEN /_7 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR -/_7 PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK4- SEWER:•LINES PIT PRIVY <br /> SEWAGE DISPOSI IELD��d-CESSPOOL/SEEPAGE .PIT' � OTHER <br /> PROPERTY LINE 4RIVATE DOMESTIC WELL' —' PU$LIC DOMESTIC USE TYPE OF WELL CONSTRUCTION SPECIFICATI S <br /> k <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing -Y <br /> eAll <br /> Irrigation Gravel Pack Depth ,of.-Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . Other Other Information <br /> Geophysical . Surface Seal 'Installed 'B , " . <br /> PUMP INSTALLATION:' - Contractor hig 0 MOV' <br /> Type .of Pump ,r <br /> H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMPS IR: State Work Done <br /> DE&TRUCTIONOF 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 toaor regulating well. "construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 FOP, A GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND 'AFINAL INSPECTIO <br /> SIGNED Is <br /> (D PLO PLAN N REVERSE SIDE <br /> R ART T USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY OATS ' !� <br /> ADDITIONAL COMMENTS.: „ <br /> PHASE I ROUTS CT- O PHASE I F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION-BY .DATE 1-2 7 7� <br /> E H 1426 .._. Rev. . -7.4- ! .. .. 3/75 2M <br />