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r 1' <br /> X <br /> i <br /> /I SAN JOAQUIN LOC',L HEALTH DISTRICT tY <br /> FOR­OFFICE USE: L� 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781N <br /> AIPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'=4 <il <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued Z o7b2- <br /> Z-r <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOA ' SLn . .� CENSUS TRACE L <br /> I <br /> Owner's Name ��_ Phone <br /> t City <br /> Address 1/2nD <br /> Contractor's Name License 4 %� r''e <br /> } TYPE OF WORK (Check): NEW WELL AY7 ?DEEPEN l�j RECONDITION /_-7 DESTRUCTION L7 i <br /> PUMP INSTALLATION /? UMP REPAIR /? PUMP REPLACEMEI.": <br /> Other <br /> b B.ISTANCE ,0 NEUJEST: SEPTIC TANK �S_ SEWER LINLS PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4?i CESSPOOL/SEEPAGE PIT OTM <br /> PROPERTY LINA: •- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Y Cable Tool ,Dia. of Well Excavation <br /> Domestic/private -�Y- Drilled Dia. of Well Casing •" p <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> � — Rota Type of Grout <br /> _ Cathodic Protectior, Rotary <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: v <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump _ H.P. — <br /> k. PUMP REpLACEME11T; /% State Work Done <br /> ,e <br /> PL'IP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree ti 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 A FINAL. INSPECTION. .� <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> _FOR DEPARTMENT USE ONLY <br /> PHASE I_ <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> Ar:jITIONAL COMMENTS: c <br /> PHASR II GROUT INSYECTI P SEMI ANAL INSPECT ON <br /> INSPECTION BY D4 F INSPECTION BY <br /> E d 1426 Rev. -74 1-74 2M <br />