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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFIC USE: 11' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I° Telephone: (209) 466-6781 <br /> ;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-4z`y1V <br /> THIS PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby made to the Snn(Colet puine In Triplicate) ( e-S-,per 0-3q Local Health District, for a permit to construct <br /> and/or install the work herein described. . This apps-ication is made in compliance with San Joaquii <br /> County Ordinance No. 1862 acid the Rules and Regulations of the Saar Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> I <br /> Owner's Name <br /> Phone , <br /> 'Address <br /> City '_ <br /> Contractor's Name �' <br /> 14-,4,1 <br /> License # Phone <br /> TYPE OF WORK (Check).- NEW WELL /7 DEEPEN ,/_7_y - x�E CANDITION /? DESTRUCTION /f <br /> PUMP INSTALLATION/ / - PUMP REPAIR ;/ PUMP REPLACEMENT /-7 <br /> Other:Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY e <br /> SEWAGEiDISPOSAL FIELD __ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> industrial <br /> A <br /> Cable-Tool Dia. of Well Excavation s <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 Protections <br /> Rotary Type of Grout <br /> Disposal Other Other Information - m ti <br /> Geophysical k '! Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> Jpj H.P. ',�-' f 7 <br /> PUMP REPLACEMENT: , / .!I/ State Work Done ' <br /> I PUMP :REPAIR: y..State Work Done-' , <br /> DES.TRUCTTON OF WELL: Well Diameter <br /> Desciibe Material and Procedure Approximate Depth <br /> i hereby agree to co' 1 g I <br /> mp y -withc 11 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 1 <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 the re putting the.-well in-use... The above f <br /> information is true Co the��best.of' ow d e and b ief. I WILL CALL -FOR A GROUT INSPECTION t <br /> PRIOR TO G OUTING AND A FINAL SPE ON �J <br /> TLE <br /> (D PLOT PLAN ON RE RSE SIDE <br /> PHASE I ; OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: jp9 DATE r� <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY 10, DATE INSPECTION BY <br /> DATE - y <br /> E H 1426 Rev. 1-74 i <br />