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4 ' SAN JOAQUIN LOCAL HE <br /> FOR, FFICE USE; - �� DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Isaued7�_�69 10 <br /> (Complete In Triplicate) 6 <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 Rales and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 S <br /> CENSUS TRACT ' <br /> Owner's Name 0�9 �1:�7e <br /> Phone ' l ri <br /> Address <br /> City ,.,St6 it f T` <br /> - <br /> Contractor's Name . . <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL.-A7 DEEPEN '/? T DESTRUCTION /7 <br /> RECONDITION # <br /> PUMP INSTALLATION / PUMP REPAIR-L-7-7-PUMP REPLACEMENT <br /> Other ._ <br /> DISTANCE TO NEAREST: SEPTIC TANK - <br /> SEWER LINESd PIT PRIVY <br /> w SEWAGE�DIS 'OSAL FIELD p CESSPOOL/SEEPAGE'PIT ZIM _ OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL C� <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation-__L2: <br /> Domestic jprivate -•.�- Dri�.led -� Dia -- ,� ff <br /> Domestic . of Well Casing W ;' <br /> /public Driven Gauge of Casing <br /> Irrigation _`__` ,y`;1 E g . <br /> Gravel Pack- Depth of Grout 5ea1 S- <br />_____�_ Cathodic Pr_otect_ionRotary Type of Grout •� <br /> Disposal <br /> „ Other _ Other Information ' ' �- <br /> Geophysical Surface Seal, Installed By: U-krrLA_ <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> H.P. I <br /> PUMP REPLACEMENT: / / State Work Done ^� <br /> PUMP :REPAIR: / / y.State Work Done _ -. <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APProximate Depth <br /> i <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.... .Tire above <br /> information i true to- the-best-of- my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION r <br />'2S?7W <br /> NG AND A FINAL <br /> CTION. <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE t <br />'RASE I FOR DEPARTMENT USE ONLY <br /> WLICATION' ACCEPTED BY <br /> 1DDITIONAL COMMENTS: DATE j a Zd� -),4 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE _jP177 <br /> E. H 1426 Rev. 1-74 w y --- <br />