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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORjOFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone-: (209)'(209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74/—5-114) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj,f9 <br /> e . I (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 ann the Rules d Reulati° of the n Joaquin Local Health District. <br /> ` - <br /> JOB �S/LOCATION CENSUS TRACT <br /> Owner's Name14A Z__ePhone <br /> Address <br /> City <br /> r / � <br /> Contractor's NameAe-7orww"5 ��Gt/ S License &&��PhoneW/'°-3'-?_/ 0 <br /> : <br /> TYPE OF WO z,k <br /> . .R�(Check). -NEW'WELL-/�J�DEEPEN-/?-�-��RECONDITION- /?.DESTRUCTION -/�^° <br /> PUMP INSTPLATION / PUMP REPAIR /-7-PW REPLACEMENT f f <br /> Other' /-7 .. '� <br /> J_ <br /> DISTANCE TO NEAREST: SEPTIC TANKj---�'► SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 'FIELD _CESSPOOL/SEEPAGE PIT OTHER <br /> - <br /> PROPERTY LIME—PRIVATE DOMESTICWELL, PUBLIC DOMESTIC WELL <br /> INTENDED .USE t ^rTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial `y., ? Cable Tool• Dia. of e11 Excavation <br /> 1r Domestic/privates ° 3- -, Drilled Dia. of Well Casing <br /> Domestic/public f 7"�. Driven 'Gauge of Casing <br /> Irrigation -� . . Gravel Pack Depth--of Grout Seal Q <br /> Cathodic Protectibn - -Rotary- Type--of�Grout' <br /> l <br /> Disposal _ Other �.�� -Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: •-{''Contractor A Ain <br /> '_Type of Pump H.P. <br /> PUMP REPLACEMENT: J/7 State Work Done <br /> F <br /> PUMP :REPAIR: /7 State Work Done <br /> i <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 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 GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN_ I INS P ION. <br /> SIGNED - TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE��. <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECT i <br /> INSPECTION BY DATE _ 1 -7)- L/ INSPECTION: BY iZ- ,- e. DATE <br /> 1 E H 1426 Rev. 1-74 <br /> 1-74 2M ��- <br />