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SAN JOAQUIN LOCACHL•'ALTH DISTRICT <br /> F05 bFF10E USE:- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6,81 <br /> APPLICATION FOR WELL CONSTRUCIION OR PUMP PERMIT Permit No. 7_5-- 5'7w <br /> INIS PERMTT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-ZE-7.f <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to eonstrwt <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 CENSUS TRACT <br /> Owner's Named c , Phone <br /> Address i 10 6I 22 ' /41t 414 City 17� <br /> Contractor's Name 111_016� J !/i `� & License 07160.Z Phone L1- SS <br /> TYPE OF WORK ((-,heck) : NEW WELL 17 DEEPEN /_7 RECONDITION /_7 DESTRUCTION Lf/� <br /> PUMP INSTALLATION Z� PUMP REPAIR /7 PUMP REPLACEMENT Lc <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 O <br /> Domestic/private Drilled Dia. of Well Casing to <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection T Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 777= <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. � . <br /> PUMP REPLACE1,1LlTT: /% State work Done n <br /> PUMP .REPAIR: /_7 State Wc.rk Done <br /> J)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> I hereby agree to comply with all lava and regulations of the San Joaquin Local Health Dis!iiet <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 /> L <br /> L DR ERS"R"EPORf the well and notify them before putting the well in use. The above <br /> orm iotf inth-_tLW of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR C L NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED HY� "'� '" DATE <br /> ADDITIONAL COMMENTS: dA/OE-!moi/ K lAS /- RY�NAL t v� <br /> /Vlv � jv PHASE 111/rins _ <br /> ON <br /> PHASE II GROUT INSPECTION //5- //t'/J DATE <br /> INSPEC1IOn BY DATE - INSPECTION BY <br /> E H 1426 Rev. :-74 '.-74 2M <br />