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R /a°d SAN JOAQUIN;LOCAL HEALTH DISTRICT i <br /> FORfoFFICE USE: 160VE. Hazelton Ave. , Stockton, Calif. <br /> "". j Telephone: (209) 466--6781 <br /> i! —APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2_ 2e <br /> if - yam. L (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 incompliance with San Joaquin <br /> County Ordinance No.°1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/Y.00ATION CENSUS TRACT <br /> Owher°.s Name rU Phone / <br /> Acitlress ' City <br /> Contractor's Name License ## !6721 Phone y.3 k- 7�-7d <br /> INi <br /> --TYPE-OF-WORR-. (Check)-:-;-NEW-WELL-E--W-fla=DEEPEN/=]- -PRECONDITION-/--7- DESTRUCTI-ON=-�f= •` - <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other' /-71: <br /> It <br /> DISTANCE TO NEAREST: SEPTIC TANK as f SEWER LINES PIT PRIVY <br /> II SEWAGE' DISPOSAL FIELD •CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE,OF WELL CONSTRUCTION SPECIFICATIONS <br /> � Industrial i Cable Tool Dia.. of Well Excavation <br /> ? Domestic/private f Drilled Y. Dia. of Well Casing Y. ' <br /> :-__ Domestic/public i Driven Gauge of ,.Casing <br /> 11. Irrigation � . <br /> j Gravel Pack Depth of Grout Seal <br /> j 1; Cathodic Protection M Rotary Type of Grout : <br /> !t Disposal 4 Other Other, Informatiom <br /> iM! Geophysical ' Surface `Seal Installed By: -- 21 d�,S <br /> PULP INSTALLATION: Contractor` y/ y M 5-r- <br /> Type of Pump H.P. <br /> P REPLACEMENT: / / State Work Done <br /> PUMP:REPAIR: /7 State Work Done , <br />,�. ESTRUCTION^OF-WELL.. ,;We11.-Diameter:- } <br /> --�-� 7-Approximate=3?epth—y;5- �- <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 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- will in use.. The above <br /> inormation•,is true to the best of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL, INSPECTION. <br /> SIGNED t TITLE <br /> —::(DRAW SIDE <br /> PLOT PLAN ON REVERSE <br /> t i FO DEPARTMENT USE ONLY <br /> PHASE' I _ <br /> APPLICATION ACCEPTED BY DATE. 7 <br /> F ADDITIONAL COMMENTS: <br /> F ���! PHA II GROUT INSPECTION PI NAL NSPECTION <br /> IA <br /> PECTiON BY DATES 2. S �� f INSPECTI�9 BY DATE <br /> E H 1426 Rev. '1-74 ,:c.F a= {.•, g , 1=74{� <br />