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JOAQUIN LOCAL HEALTH DISTRICT <br /> 'ORrOFFICE USE: 160 . Hazelton Ave. , Stockton, Cali_.._ E <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued J2 -,�Lµ-2 7 <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a pelt to construct <br /> id/or .install the work herein described. This application is made in compliance with San Joaquin <br /> Runty Ordinance No. 1862 and the Pules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION / �� S . ( �i .tz. k'c�, - CENSUS TRACT <br /> ,rner s Name �ti a �_ r�t�C.�S C �� - --- Phone <br /> 3dress f _ .S l��e c; ter ._ Ct,_• City ask <br /> ontractor's Name _/ le� Cie. License # Phone <br /> i <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /-7 DESTRUCTION ff <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY IN <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �y <br /> Domestic/private Drilled Dia. of Well Casing L+ � <br /> Domestic/public Driven Gauge of Casing ( < <br /> _IL_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By,;_..,._..,.__ -- <br /> 'UMP INSTALLATION: Contractor ij }S ite.�� ,� vi <br /> Type of Pump _ " H.P. j 6 4 <br /> ?UMP REPLACEMENT: / / State Work Done <br /> i <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 /> 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 /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �� z � _ TITLE i - <br /> ` '^ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9-,937_? - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION P III/ NAL INSPECTIO <br /> INSPECTION BY / DATE INSPECTION B DATE11-7 <br /> E H 1426 Rev. 1-74 1-74 2M <br />