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f7f ' 3 <br /> / 5 / SAN JOAQUIN LOCAL HEALTH DIS3CT <br /> Fo—ToUSE: 1601 E. Hazelton Ave. , Stockton', PCalif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 7�4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4K-7zF <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. 186 the QR les and /Regulations of the San Joaquin Local Health District. <br /> J C3J `A 11`77� f �~sl �-". <br /> JOB ADDRESS/LOCATION / �"�- � CENSUS TRACT <br /> Owner's Name "'- f: Phone "7 . <br /> Address / J.,v"P_�Tro, 1 City 7170 e-1<7-V <br /> Contractor's Name jI e4l <br /> License � ���hon <br /> TYPE OF WORK (Check) :r NEW WELL / DEEPEN /_7 'RECONDITION /_7 DESTRUCTION / " <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1406 EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD J6-6 7-CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �2 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPACR7: &7- State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter , Appoximate Depth <br /> terial and Procedureu• <br /> Describe �Ia X: <br /> I hereby agree to comply with all laws and regulations of the San Jo quin Loc FHes�lgh,'Dtstrict <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 fTITLE ° <br /> (DRAW'PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �L 7 <br /> ADDITIONAL COMMENTS: z:EZ!= <br /> PHASE II GROUT INSPECTION PHASE III N fINSPECTI N <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />