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A� <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT SCANNED <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. / <br /> 209: <br /> Tele hone466-6781 <br /> P ( ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -7-7Permit No. ^T <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 /> JOB ADDRESS/LOCATION /Q 72 4 <br /> � � CENSUS TRACT <br /> Owner's Name Phone <br /> 5;� � 7 <br /> Addressoe <br /> City jL�c� 2.-.� <br /> Contractor's Name cmc K� License hone s <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FPIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 13. <br /> Industrial Cable Tool Dia, of Well Excavation .�� f' J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing '� C 16Cn <br /> Irrigation Gravel Pack Depth of Grout Seal f' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: /V1 j__ e, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <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 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 th e 1 and notify them before putting the .well in use. The above <br /> information is true t_q t -best my owled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI INSPECTI N <br /> SIGNED TITLE ` <br /> (PAW PLOT PLAN ON REVERSE SIDE) <br /> } FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA UT INSPECTION PHASE INSPECTION <br /> INSPECTION BY DATE p - INSPECTION BY DATE <br /> 1/77 2M <br /> H 1426Rev.__­j.-7__4.,, T7 <br />