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CO /PJ Afl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFO ;OPFI?CE USE: jj// 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. 746_a 47 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued U-/3 76 <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 Josqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> a, j <br /> JOB ADDRESS/LOCATION a OQ 17 fir &f -;L)w CENSUS TRACT' <br /> Citv.".4' <br /> Contractor's Name License # " Phone <br /> TYPE OF WORK (Check): .NEW jQELL'/? DEEPEN '/? RECONDITION'/? DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION O PUMP REPAIR'/ PUMP REPLACEMENT /7 <br /> 1 -Other El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'T PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ', }t Domestic/private Drilled _ Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'p Irrigation Gravel Pack bepth of Grout Seal <br /> Cathodic Protection Rotary f Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal 'Ins talled By: C <br /> ,I PUMP INSTALLATION: Contractor w^ i� t <br /> Type of Pump A 4kl/b Ad, H.P. <br /> ' PUMP REPLACEMENT: L/ State Work Done - ' I <br /> PUMP lmna: k7 State Work Done Waw/ 4✓�� <br /> 19 <br /> DES+TRUCTION 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.Diatrict <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 DRfLLERS 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 INSPERIDN t!r cs <br /> SIGNED TITLE <br /> ' DRAW PLOT PLAN VERSE SIDE <br /> FOR rAPILRTMENT U"rE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPT AL .OLS EN DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE i INSPECTION <br /> ' . INSPECTiOA BY DATE INSPECTION BY ATE <br /> 6 E R 1426 Rev. 1-74 y/75 <br />