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S/ JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 a: Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--j 6W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _3 y �S <br /> In <br /> Application is hereby made to the San (Joaquin eLocal rHealth tDistrict 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/LOCATION S / 0 CENSUS TRACT <br /> Owner's Name1C0��� /(7iGE Phone �(� <br /> Address City i� <br /> Contractor's Name 1 i License Phone <br /> TYPE OF WORK (Check) : NEW WELL -7 DEEPEN /_7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR F7 PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,7�— SEWER LINES PIT PRIVY <br /> SEWAGE DISPO ff 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 /e? ?/ <br />_\ Domestic/private Drilled Dia, of Well Casing �, <br /> Domestic/public Driven Gauge of Casing /• <br /> Irrigation Gravel Pack Depth of Grout Seal 4-A <br /> Cathodic Protection }t Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br />'UMP INSTALLATION: Contractor ,L"'r- c+ <' -�Zld <br /> Type of Pump H.P. i <br />'UMP REPLACEMENT: / / State Work Done <br />?UMP '.REPAIR: / / State Work Done <br />>ESTRUCTION OF WELL: Well Diameter Approximate Depth j <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lod 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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />'.nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING D Af FTrjAT INSPECTION. <br /> UUNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR_DRPARTMENT USE ONLY <br />'RASE I <br /> LPPLICATION ACCEPTED BY t GL/. DATE '/ 7 <br /> LDDITIONAL COMMENTS: <br /> PHASE, l 'aROUT INSPECTION PHASE A141FI INSPECTION _ <br /> CNSPECTION BY DATE 5 INSPECTION BY/ DATE <br /> - E H 1426 Rev. 1-74 1-74 2M <br />