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1N JOAQUIN LOCAL HEALTH DISTRIG� <br /> OF F OFFICE USE: 16M E. Hazelton Ave . , Stockton, Calif . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-f 6V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 -/i -75 <br /> (Complete In Triplicate) <br /> Application 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �S / CENSUS TRACT <br /> Owner's Name l[ /(}/GfirysG.., Phone <br /> Address <br /> City C'l' <br /> c <br /> Contractor's Name ,j-e 1_ . License #"« Phone <br /> TYPE OF WORK (Check) : NEW WELL -7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 (1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT_ /-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection SS Rotary Type of .Grout <br /> Disposal Other Other Information ac <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - / i?r %xlt� <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> PRIOR TO GROUTING AND d FTNAT INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 5 -b i „/� � DATE j <br /> ADDITIONAL COMMENTS: <br /> PHASE, Ij,,jGROUT INSPECTION PHASE /FINAL INSPECTION _ <br /> INSPECTION BY DXT-E = 74 INSPECTION BY< DATE - <br /> �� E H 1626 ua.. 7_7A <br />