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C� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOR-OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:• p (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6_,3,�/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7e' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local llealth.Distriet 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/LOCATION g rI [ !,� CENSUS TRACT <br /> 3 <br /> Owner's Name v 0�,!' <br /> Motel ❑Other -------------------------------------------- { <br /> N„mher of livina units:_.-------- <br /> -- Num9er of bedrooms ,_-Garbage Grinder ?_____y_ Lot Size <br /> Contractor's Nam / cif �t <br /> License # /' 2S Phone -74 <br /> TYPE OF WORK (Check): NEW WELL"/77 DEEPEN '/? RECONDITION. /7 DESTRUCTION /f <br /> 4 PUMP INSTALLATION / / PUMP. REPAIRv/_7 PUMP REPLACEMENT <br /> ' <br /> Other <br /> /_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 \ 1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _- X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> F Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information . . <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorSs ,y,/ o,y <br /> Type of Pump ✓ c-yr-e H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,,REPAIR: State Work Done E <br /> .h <br /> DESTRUCTION 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 i <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 OTi- Y kibw and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO-ZROUTING AND A FINAL I-NSPE'Cfto� . <br /> SIGNED TITLE <br /> (/ <br /> (DRAW T PLAN ON UVERSE SIDE <br /> m <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . <br /> w PHASE II GROUT INSPECTION PHASE II FINAL INSPE ON <br /> INSPECTION BY DATE INSPECTION BY i DATE j T <br /> E R 1426 Rev. 1-74 h/75 2M . <br />