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f SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOSfOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7-ir5-� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUk1'P PERMIT Permit No. 75---5 -3 <br /> X�} <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �f <br /> �!(F7?"Z s r�{cr r ,o ✓SCJ ' (Complete In Triplicate) int$--[fp s <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 Rules and Regulations of the San Joaquin Local stealth District. <br /> JOB ADDRESS/LOCATION E t CENSUS TRACT <br /> Owner°s Name Picone �f�(z ~rAcyl I <br /> ` Address r f 'i -. - . City <br /> Contractor's Name License ft,; ae f Phone - <br /> f A <br /> TYPE OF WORK (Check) : NEW WELL49 <br /> DEEPEN '/? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION 0/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE NRARi+: T: ' SEPTIC TANK SEWER LINES PIT PRIVY <br /> l`l SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 0 y✓�' PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INDED,-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private Drilled Dia. of Well Casing ?LW LO " <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation # Gravel Pack Depth of Grout S al <br /> Cathodic Protection Rotary Type of Grout <br /> j Disposal Other Other Information <br /> f Geophysical 'Surface Seal Installed By: 41 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. lab, T „ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /-7 State Work Done <br /> 2ES;TRUCTION 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 <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 CALJL., FOR A'GROUT INSPECTIONF <br /> PRIOR jq 82UTING AN ;FINAL INSPECTION. <br /> SIGNE ' TITLE f <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Z FINAL INSPECTION <br /> INSPECTION BY t DATE INSPECTION BY DATE <br /> �.� E H 1426 . Rev. 1-74 1-74 2M <br />