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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r. <br /> For, OFFICE USE: 1601 E. Hazelton Ave. ,-,Stockton, Calif. <br /> 4 . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: <br /> (Complete In Triplicate) ;2_0 3- 0&,o_1_37 <br /> 9pplication is $ereby` 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/LOCATIONe'IF^fib9 t '�— /XL.�DZSy�OrNd1l/e®� �L6O^-- CENSUS TRACT <br /> Owner's Name " Com[ hone <br /> Address City 1 <br /> Contractor's Name ����' itil4 5. (�}/1�.� o� . License # #Y/ Phone <br /> TYPE-OF WORK (Che'ck) :^-NEW-WELL-lam DEEPEN-/-7 RECONDITION /_— DESTRUCTION- - - --- - - 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / � PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jdej SEWER LINES �1_ .PIT PRIVYff `) ! <br /> SEWAGE DISPOSAL FIELDgouS CESSPOOL/SEEPAGE Plf A4 OTHER . <br /> PROPERTY LINE PRIVATE DOMESTIC WELL tldkQ/PUBLIC DOMESTIC WELL d d ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; �•± <br /> Industrial I Cable Tool Dia. of Well Excavation '.2411 <br /> Domestic/private t Drilled Dia. of4e11 Casing �! <br /> Domestic/public 1Driven Gauge of4Casing <br /> Irrigation ! Gravel Pack Depth of'Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Instal�iled By: <br /> PUMP INSTALLATION: Contractor ,< ��" S''111� �.� <br /> Type of Pump ✓- ?9 ACi A H.P. 7 _ <br /> PUMP REPLACEMENT: / ./ State Work Done ' <br /> PUMP REPAIR: /-7 State. Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . rJ <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 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 GRpUTING AND SP <br /> NAL INECTION. n <br /> SIGNED ��i TITLE �{ <br /> DRAW PLOT P ON REVERSE SIDE -7 <br /> FOR DEPARTMENT USE ONLY <br /> PY•SE I <br /> A ICATION ACCEPTED BY DATE/2 S -_7 <br /> ADMITIONAL COMMENTS: ' <br /> ' PHASE II GROUT'INSPECTION - - - ;PHASE II /FIN INSPECTION <br /> INSPECTION BYtDATEa INSPECTION BY DATE 7� <br /> III ---�F-� ?�F!' <br /> 1 177 <br /> 1 E H 1426 Rev. 1-74 <br />