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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: ; 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -7 a <br /> 76-96 7}0 <br /> -."THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 and the Rules and Regulations of the San -Joaquin Local Health District' <br /> 7 <br /> .TOB ADDRESS/LOCATION � <br /> � - �� . ��� � CENSUS TRACT , <br /> Owner's Name -73/_ V7, <br /> Phone ' <br /> Address _ <br /> Citq <br /> 47 <br /> Contractor's Name License - Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN I-7 RECONDITION /-7 ' DESTRUCTION j j <br /> PUMP INSTALLATION /��PUMP REPAIR /? PUMPREPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ZX2Z CESSPOOL/SEEPAGE PIT, -" OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DC)MES- C WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "11 <br /> ,Industrial ,,---Cable Tool Dia. of Well Excavation <br />=----Domestic/private Dia.. of Well Casing cy" <br /> Domestic/public. Driven '-Gage of Casing AJ _ <br /> Irrigation Graved. Pack Depth of Grout Seal ':Z)/ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe�B fes. ' <br /> PUMP INSTALLATION: Contractor <br /> 42 <br /> } <br /> Type P£ Pins _ H.P. <br /> PUMP REPLACEMENT c / / State Work Done <br /> PUMP '.REPAIR: f <br /> State Work ,Done <br /> . r <br /> DESjTRUCTION OF WELL: Well ter APProiimate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllaws-and--regulations of the San ,Joaquin Local Health District <br /> and the State of California pertaining to or regulating weil`const�ruction. 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�REPCIRT.._of. the-well-and-notif y=them-before put-ting'the 7­wel3 in:tsse:.': TheMb`ovd"—� <br /> information is true to- the-best -of my-knowledge and belief;-1 ,I WILL-.CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL I SPE ION., <br /> SIGNED TITLE <br /> s` <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CONMENTS: <br /> PHA INSPECTIONr PH&U YINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E 8 1426 rev. 1- 4 1/`.ho-�4 "e�/.T �.n,� ��? ' ". •� <br /> 7 W -moi ! h/75 2M __ <br />