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e SAN JOAQUIN LOCAL HEALTH DISTRICT IJ <br /> FORT-OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. 7,V-:fj��� <br /> 1 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /L-/.V__2c1 <br /> (Complete In Triplicate) q3-rrn-oL <br /> Application is herebymade to the San Joaquin Local. Health District for a permit to konstruct <br /> and/or instal, the work herein described. This application is wade in compliance with San Joaquin: <br /> County Ordinance No. .1862 and <br /> theles and Regulations of the San Joaquin Local health District. <br /> ,SOB ADDRESS/LOCATION , X CENSUS TRACT <br /> Owner's Name /i <br /> �`.�'� v Phone .4 f <br /> Address r[ City <br /> Contractor's Name �C4G/� <br /> License hondV <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION 07PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other <br /> i <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 3 Cable Tool Dia. of Well Excavation 1 `h <br /> Domestic 4 u <br /> Domestic/private � Drilled Dia. of Well Casing I <br /> + Domestic/public Driven Gauge of Casing <br /> Irrigation 4 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 /> ! 4 <br /> PUMP INSTALLATION: Contractor <br /> ti Type of Pump H.P. S I <br /> PUMP REPLACEMENT: . ' <br /> / / State Work Done �.- <br /> . . a <br /> PUMP REPAIR: <br /> / / State Work Done <br /> ¢,.DES.-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 /> 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 the well and notify them before putting-the-well in-use.. The above <br /> information is t to the. my kn ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO FINAL INSP � ; <br /> SIGNED ,�` .,�� 1 TITL ' <br /> DRAW PLOT PLAN ON REVERSE SI <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 7 <br /> (� <br /> �� / : <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE <br /> INSPECTION. BY 2 "] DATE <br /> 4 <br /> 5 <br /> E H 1426 Rev. 1-74 1-74 2M <br />