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T SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE _OFFICE—USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)• 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuede--77 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Joagvin <br /> County Ordinann2ce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC <br /> AT ONS <br /> luprn- e CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2 <br /> q,5j, City <br /> Contractor's Name License Phone <br /> d -�. J�-113/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK �d� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 0A/ CESSPOOL/SEEPAGE PIT OTHER <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 A � <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing V4 Q0- <br /> Irrigation Gravel Pack Depth of Grout Seal Koh p <br /> Cathodic Protection X _ Rotary Type of Grout <br /> 093 ng-- <br />-Disposal Other Other Information <br /> GeophysicalSurface Seal Installed B : <br /> PUMP INSTALLATION: Contractor Q y� # �'✓ � �- � �.. <br /> � � �L.Jv�lc-f C�-�`� <br /> Type of Pump H.P. /gyp <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done 7 6 —7-l <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 bistrict <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 District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGND , TITLE <br /> 'An (DRAW PLOT PLAN 0 REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G Uj INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY <br /> E eH 1426 Rev. 1-74 -�� G� �-3 =7�/ 1,410k <br />