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rO ��© 1 .SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FORtOFFICE USE: 1601 E. 'Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��;# <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dace Issued /-2-3-74 <br /> (Complete In Triplicate) 7---`170-01 <br /> Application is hereby made tothe San Joaquin Local Health District--for-'a parmit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.. .1862 andathe Rules and Regulations of the San Joaquin Local Health District. <br /> eA 740< <br /> JOB ADDRESS/LOCATION l+} s c*An�l CENSUS TRACT <br /> Ownerts Name 14 Phone / <br /> Address " �� 0 :`. Q.4�r/ City <br /> Contractors Name License /5 d 7zr~Phone 7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN- /7--RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /-7—PUMP REPAIR 1-7 PUMP REPLACEMENT <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 �v <br /> Domestic/private. ' Drilled Dia. of Well Casing �1 <br /> Domestic/public Driven Gauge of Casing �l <br /> Y 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 /> PUMP INSTALLATION: Contractor : <br /> Type of Pump �",,ob H.P. <br /> PUMP REPLACEMENT: /X/ State Work Doneo! hr e <br /> PUMP '.REPAIR: -7 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 /> Y 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 kncgotledge and belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INMCT1, <br /> SIGNED ITLE <br /> RAW LOT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ( DATE <br /> t. E H 1426 Rev. 1-74 1-74 2M <br />