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K: 1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> zx <br /> to <br /> j mow. THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED.. �-. .,: Date Issued� <br /> (Complete In Triplicate) L; ,, „54 • " <br /> a Application is hereby made to the San Joaquin Local Health District for s'permit' to. construct <br /> and/or install the work :lhereia described. This application is made in- cdipliance' with San,Joaqu M <br />.'fCounty Ordinance No. 1862 and the Rules and Regulations of the San:`-Joaquin','Local'--Health District'. <br /> JOB ADDRESS/LOCATION ,. �-wd:��`j �i : M CENSUS..TRACT .;.. <br /> x <br /> '`.Owner's Name PhoAe_ ? j� <br /> r .. <br /> ",Address 7 _:Citq <br /> `.Contractor's Name License' biie. p <br /> 'TYPE OF WORK (Check): NEW WELL ' DEEPEN ,/7 RECONDITION /_ J <br /> 7 ° DESTRUCTION-`/-J <br /> PUMP INSTALLATION "/ / PUMP REPAIR I? PUMP REPLACEMENT / f� <br /> Other / / <br /> ISTANCE TO NEAREST: SEPTIC TANK IPp SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE '.PIT OTHER <br /> 4. <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 /> IrrigationGravel Pack- Depth of. Grout=Seal' <br /> Cathodic Protection w Rotary Type of Grout, <br /> TiisposalOther . Other Information, F <br /> Geophysical.. II. Surface Seal. Installed"Byt^ 3 <br /> ,PUMP INSTALLATION: Contractor 12,0Z <br /> Type .of Pump H.P.. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP :REPAIR: j7 State Work Done ; <br /> 2ES1RUCTION OF WELL: Well Diameter Approximate Depth`_/� / k <br /> ! _ Describe Material and Procedure <br /> i .hereby agree to comply with all laws and- regulations of the Sari-Joaquin",Local Health'Di6trIct <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 Districtfa <br /> i JELL DRILLERS REPORT of!�ithe well and notify them before putting.the..we11; in.use... The above <br /> ,information is true to the-best-of. my.-knowledge and belief. I WILL CALL 'FOR A`GROUT INSPECTI N :', <br /> P�IOR TO GROUTING AND A-(FINAL INSPECTION. <br /> t9IGNED TITLE <br /> ip . DRAW PLOT PLAN ON REVERSE SID <br /> f ! FOR 'DEPARTMENT USE ONLY t <br /> PHASE i <br /> APPLICATION ACCEPTED By DATE <br /> ,ADDITIONAL COMMENTS: . k <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ii DATE INSPECTION BY, DATE 7 <br /> F I :4 <br /> E H 1426 Rev. '1-74 -- h/75 . 2M <br />