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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT d r►� �o� <br /> FORIO ICE US 1601 E. Hazelton Ave i , Stockton, Califf.,'IAIOS . 5 . �R;Loe k_rO.4/ )eb . <br /> Telephone: (209) 466-6781 �_. GR'�h� ��� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-s=363Lc� <br /> THIS PERMIT EXPIRES 1 YEARjFROM DATE ISSUED Date Issued S:7S s <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 /> JOB ADDRESS/LOCATION - S U SA CENSUS TRACT <br /> Ownet-''s Name S7 Phone 9,q8' - 716;L <br /> Address e ,•� City e <br /> 3 <br /> Contractor's Name License # Phone <br /> I. <br /> TYPE'.OF WORK (Check): NEW WELL /7-___D'EEPEN -/-7 RECONDITION /7 DESTRUCTION /�- <br /> PUMP INSTALLATION L/ PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC.TAN&� t SEWER LINES PIT. PRIVY <br /> 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 Cable- Tools Dia. of Well Excavation <br /> � Domestic/privative :: - Drii ed YDia. of Well Casing ley <br /> _ omestic%public.. -Driven,-- Gauge of-Casing <br /> Irrigation i `" &.7�xavel Pack Depth of Grout Seal <br /> s <br /> Cathodic Protection "atary Type of Grout <br /> Disposal ' . .. - Other Other Information <br /> Geophysical Surface Sea] installed By: <br /> i � •I <br /> PUMP INSTALLATION: Contractor <br /> 1: F Type of Pump_ .. A.P.: <br /> `PUMP' REPLACEMENTi State Work Done <br /> ,PUMP�12EPAIR: L7 State Work Done - <br /> ,DESTRUCTION OF WELL: Well Diameter Z . Approximate Depth Po <br /> Describe Material and Procedure Af4 F _ <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.,a new well, • I,.wil.1_.fumish•„the__San..Joaquin.._Local-Realth..-Dfstriet a <br /> WELL'`'rDRILLERS-REPORT of the•well and -notify theme before-'putting -the.-wel1�-_in.use..;• .The above <br /> information-is -true--to-the'best sof• my}knowledge-and=belief`.—I-'WILL CALL FOR ' 'GROUT-INSPECTION" <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE• Z <br /> ADDITIONAL COMMENTS: <br /> PUM II4GW INSP&gION PHASE III NAL INSPECTION -� <br /> INSPECTION BY it. DATE 7 INSPE IONBY DATE <br /> 4 µBaH <br /> i <br /> 3426 Rev. 1-74 "` _� �� 1-74 2M <br />