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t 1/ SAN JOAQUIN tCCAL7HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave; 'Stockton, Calif. <br /> Telephone,: x:.(209-Y 4W-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.._7--21? W � <br /> THIS PERMIT EXPIRES I .YEAR. FROM •DATE ISSUED Date Issued 3_/6.7 7 <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 herein described. This application is made -in compliance with San Joaquin <br /> County Ordinance No.° 3.862 and the Rules and!Regulations,:of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &l e 14, 1 W rr CENSUS TRACT <br /> Owner's Name r Phone 3 69 - 2-3 ,70 <br /> Address. Z C _ _, est os �� .` -.� City !27--a e h'a•v <br /> 2X c <br /> Contractor's Name. f' .... License-4 Phonefkl-01.7q <br /> TYPE OF WORK (Check_ ). 9EW WELL / ?i - DEEPEN /-7RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other <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 Q <br /> Industrial Cable Tool Dia. of Well Excavatioai <br /> _ Domestic/private ± Drilled Dia: of -Well Casing W, �1 <br /> Domestic/public Driven Gauge: of Casing.- 12— <br /> Irrigation <br /> 2—Irrigation Gravel Pack Depth of GroutjSeal <br /> Cathodic Protection s RotaryType-%f-Grout= *R ,u-, ETA _. <br /> - � Disposal t Other `,1Othex'Information. <br /> Geophysical ;� ; Surface Seal Installed Sy: vjy jrrjr,00 v�sr► 4� <br /> f` Tom' r <br /> PUMP INSTALLATION: Contractors (l� ,C u. s <br /> Type a Pump H.P. .s <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP '.REPAIR: /_7 State Work Done <br />' MS.-TRUCTION OF WELL:. _ : Well. Diameter - W` --` 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 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 GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE ..- <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BY <br /> _7 41 DATE .- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ell <br />� ? E H 1426 Rev. 1-74 1-74 2M <br />