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h J JOAQUIN LOCAL HEALTH DISTRIC'__ <br /> F�OF OFFICE USE: 1 / 160rE. Hazelton Ave. , Stockton, Calif. <br /> VVV Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/,/_3 5-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�7-9-7 <br /> (Complete In Triplicate) <br /> -,pplication 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 Joaquir <br /> .:ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /c:2 � /A- <br /> ,IhIVT-1( Y Z�C CENSUS TRACT <br /> Jwner Is Name ! ��3 ��� / �p OU C �� Phone <br /> // <br /> Address ✓ J��OJ City <br /> /bt ' 3 9-4 3f <br /> Cont ctor's Name License # Phone <br /> rvPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 Cn <br /> Other <br /> / ! <br /> '!STANCE TO NEAREST: SEPTIC TANK SEWE LINE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4"� 'i_CESSPOOL/SEEPAGE PIT OTHER �Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIqaTONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -� Domestic/public Driven Gauge of Casing eD <br /> _ Irrigation _�( Gravel Pack Depth of Grout Seal � <br /> _ Cathodic Protection X Rotary Type of Grout Q J <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump T"L /fv H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ?UMP .REPAIR: /% State Work Done <br /> )ES•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 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 /> ;ELL 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 /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> a� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY / o J A ,ti� / I J . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F CAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z- <br /> E H 1426 Rev. 1-74 1-74 2M <br />