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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,. Telephone: (209) 466-6781 <br /> APPLICATION•�-FOR WE'LL*,CONSTRUCTION OR PUMP PERMIT Permit No. ��� ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d <br /> (Complete In Triplicate), Qt3 -?�'o-- f <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 Regulat'ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACTI ; <br /> Owner's Name f �- �� Phone 3 3 T ,Z J z <br /> Address 3 } City <br /> Contractor's Name License #,?jjVf#Phone F <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ) DEEPEN '/ J RECONDITION /-7 DESTRUCTION /� F <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/� SEWER LINES f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _Luff+ CESSPOOL/SEEPAGE PIT OTHER <br /> ROPERWELL PUBLIC DOMESTIC_ WELL JJOQ f <br /> INTENDED USE <br /> PROPERTY WEPRIVATE DOMESTIC <br /> PEO -_ ,•,.....,---CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation T-3-77--- <br /> Domestic/private <br /> 3 -Domestic/private Drilled Dia. of Well Casing _—21 <br /> X Domestic/public Driven Gauge of Casing -Apt- <br /> Irrigation <br /> Gravel <br /> IrrigationGravel Pack Depth of Group_ SealEl <br /> Cathodic Protection X Rotary Type ,.of Grout / s?YA- J,f "I,'.,F <br /> Disposal Other ,,.Other Information <br /> Geophysical Surface, Seal'-Installed BY: d-*fP.S <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump &Z ` H.P. 342 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> E <br /> DESTRUCTION OF.WEL_ L: Well"Diameter\i , A Al Approximate-Depth <br /> Describe• ,.Miterial. and Procedure <br /> k <br /> I hereby agree to comply with all laws and regulations of the San Joa4.uin 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 t the-bes of- my..knowledge and belief. I WILL CALL FORA; ROUT INSPECTION <br /> PRIOR TO .ROU AN AFI NSPE ON. <br /> SIGNED TITLE' <br /> D W- PLT PLAN 'ON REVERSE SIDE <br /> PHASE I. 1 > . - ,, <br /> FOR DEPARTMENT USE ONLY <br /> , Y - <br /> APPLICATION ACCEPTED BY DATE 6- 7- 7P <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY �` f DATE <br /> E H 1426 Rev. 1-74 376 2M <br />