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j SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> P'OE OFFICE USE: 1601 E. Hazelton'Ave_ .`", Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT ,EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _T-.2,7-74 <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 egulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION D CENSUS TRACT r` <br /> Owner's Na f_ Phone <br /> Address City G <br /> Contractor's Name `} License �� Q /, Phone •,j,Z,Z /C�dl <br /> TYPE OF WORK (Check) : NEW WELL�/ DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTLATION REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SQ PIT PRIVY oi✓of_� - <br /> SEWAGE DISPOSAIy FIELD �f CESSPOOL/SEEPAGE PITA--,A�77 OTHER <br /> PROPERTY LINE/6-PRIVATE DOMESTIC WELL PUBLIC iTV7q1TTr WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> L_- Domestic/private 4,,Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -- #7 H� <br /> Irrigation Gravel. Pack Depth of Grout Seal .3-7' <br /> Cathodic Protection .y—Rotary Type of Grout ` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL:*Well Diameter Approximate Depth �D <br /> Describe Material and Procedure <br /> o w,VF1t G q-r a ,'/Z 1'tZ AA,4n/,0 0^17,27 a^der <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 G OUTING AND A WNAL IN RECTION, <br /> SIGNED ? l ITLEL�' <br /> D W.PLOT LAN ON REV' SE SID , <br /> FOR DEPARTMENT USE ONLY <br /> OKJ <br /> PHASE I p <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT NSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY G✓ DATEx-4;2-7 <br /> dl�'1 0 �/L . <br /> E H 1426 Rev. 1-74 <br />