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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: j 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �� C! Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;Z7-Sl� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued 7-1-5 <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 wor0 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 />' JOB ADDRESS/LOCATIONg;!Ar, "`' - a�. CENSUS TRACT <br /> Owner's. Name i1/' , Looe _ Phone <br /> Address. 3 / r City <br /> Contractor's Name A ,. License #1 Phone y? <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION- / / PUMP REPAIR /)e/ PUMP REPLACEMENT /-7 <br /> . Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <:1a CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY LINE - PRIVATE"DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> i.JINTENDED 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 i Driven. Gauge of Casing <br /> Y .11.Irrigation �� -vGravel Pack Depth of Grout Seal <br /> Cathodic Protection -%Rotary Type of Grout <br /> E Disposal Other _ Other Information <br /> '.!Geophysical Surface Seal Installed B :—"^` <br /> PUMP INSTALLATION: Contractor <br /> ., Type of Pump .►• e:' a H.P. 3 0 { <br /> PUMP REPLACEMENT: 7 / State Work Done <br /> I PUMP .1REPAIR: /)f/ State Work DoneJr <br /> - <br /> DESTRUCTION OF WELL: =Well Diameter 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 Che State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my , al Health District a <br /> 'work on a new well, I will furnish the San Joaquin Loc <br /> WELLil4DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true toj�the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ?RIOR TO GA&U ING AND A FINAL C IO <br /> IE GN _6e,, TITLE <br /> ;F6DW PLOT PLAN. ON ERSE SIDE) <br /> FOR DEPARTMENT USE. ONLY <br /> i <br /> DATE /1h2 <br /> 'CATION ACCEPTED BY '� <br /> `ONAL COMMENTS: I9 <br /> PHASE 11 GROUT INSPECTION PHAS I / AL INSP CTIO <br /> �. ON BY ADATE INSPECTION BY DATE z' <br /> d� . 1177 , : 2M <br /> ;" 6 Rev. 1-74 <br />