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SAN JOAQUIN LOCAL -HEALTH DISTRICT K <br /> FOfi0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73'-.2,)5�W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 hevAn described. ` This application is made in compliance with San Joaquin <br /> County Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> • 7-2.S' .4. 14 <br />` `JOB ADDRESS/LOCATION ` -;-�7n.Ze CENSUS- TRACT <br /> Owner's Name i Phone .3 G L -�c V-74V <br /> Address :.S G+ City -1 <br /> Contractor's Name ""`" License V413 7 Phone Co <br /> TYPE OF WORK (Check) : NEW WELL . DEEPEN /? PRECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION PUMP REPAIR /� PUMP REPLACEMENT %7 <br /> Other L 7 dticl.Ge� ---i <br /> � y <br /> DISTANCE TO NEAREST: SEPTIC TANK loo' SEWER LINES Sp PIT PRIVY <br /> SEWAGg"DISPOSAL FIELD'/S� CESSPOOL/.SEEPAGE FIT OTHER <br /> PROPERTY-LINE - PRIVATE DOMESTIC WELL' PUBLIC°DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL L- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /0 .10 <br /> X_ Domestic/private' 4 + Drilled Dia.. of Well Casing i •• <br /> Domestic/public r Driven Gauge of Casing % <br /> .Irrigation ' ' Gravel Pack Depth of Grout Seal d <br /> _-Cathodic Protection x Rotary- E Type of Grout (� <br /> Disposal I Other Other Information }` <br /> Geophysical_ 'Surface Seal Installed By: <br /> n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / Y <br /> PUMP REPLACEMENT: / / , State Work Done <br /> PUMP '.REPAIR: . --- - /7StatEWorkDone. <br /> �- - - - - <br /> pESmRUCTSON OF WELL: Well Diameter Approximate Depth <br /> r 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 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 GEIF AND FIM INSPEqTION. <br /> SIGNED TITLE /l <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> . r . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G6. DATE 7S— <br /> ADDITIONAL COMMENTS: � . aG �r <br /> i PHASE II GRO T INSPECTION PHASE III FINAL INSPECTION <br /> f INSPECTION BY ATE s� INSPECTION: BY DATE -S l s <br /> 'i ^E H 1426 Rev. 1-74 1-74 2M7 <br />