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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 1� � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Y 7 <br /> -(Complete In Triplicate) Z�q �U7U—Q <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 Ordinanc N. 1862 he Rules a d Re u al-ions of. the San q i L cal Health District. ` <br /> JOB ADDRESS/LOCATI �l 5 (�/F� N 13 '1 P Cp,4_CENSUS TRACT 4 <br /> rb M�r� � ; <br /> Owner s Name C��/ Phone -- 030/5/ <br /> Address u P L L ec" City I <br /> I <br /> Contractor's Name - cadmL License3(� Phone q��-6 ( <br /> TYPE'OF WORK (Check)+: NEW WELL/�EEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP' INSTALLATION / UMP REPAIR/ / PUMP REPLACEMENT I-T <br /> Other / I <br /> DISTANCE. T-0 NEAREST: ' SEPTIC TANKS_z� SEWER LINE Dom--PIT PRIVY ----- I <br /> `-SEWAGE DISPOSAL FIELDS--CESSPOOL/SEEPAGE PIT /razr-COTHER y <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ; teary Type of Grout <br /> '^ - <br /> 'Disposal ? Other Other Information.�rS'�,4, ��a P• <br /> Geophysical Surface Seal Installed B , S. /A C <br /> PUMP INSTALLATION: Contractor.._ <br /> Type of Pump e H.P,. 3 ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / <br /> State Work Done �' r <br /> � <br /> DESTRUCTION OF WELL: Well Diameter T 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 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> inform on is true to the �knowledge and belief. } I- WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING ANDA N I <br /> SIGNE ` ._ TITLE -�/ <br /> W PLOT PLAN ON REVL'kSE SIDE) <br /> FOR DEPARTME T USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> fPHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> i INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76M <br /> E H 1426 j Rev. 1-74 �.. o , . �2 <br />