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-- - - <br /> ��f/// SAN JOAQUTN LOCAL-HEALTH D7STR:CCT <br /> FO&jOFFICE USE: 1601 E. Hazelton .Ave:, •Stockton, Calif. <br /> Telephone: (209)_466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5� 3. �✓ : <br /> THIS #PERMIT EXPIRES l YEAR,FROM>DATE ISSUED Bate Issued 7—.0-75­ <br /> '.. <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. 1862:and the Rules and, Reguiations„.of.the Sart Joaquin Local Health District. � <br /> 4 <br /> JOB ADDRESS/LOCATION j t,� l�ViZ 1b <: �. .- < , CENSUS TRACT <br /> Owner s Name�., ,. �a P art r>- .� Phone "0 A-) <br /> Address- gisc a l'o <br /> Contractor'a .Namef,,•_1147 Fv. License Phone <br /> TYPE OF WORK• (Check) : NEW-WELL /_ DEEPEN '/-7- RECONDITION /_7 DESTRUCTION (7 <br /> PUMP INSTALLATION PUMP REPAIR ./ / PUMP REPLACEMENT /_T .� <br /> .. . _ <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 /> INTENDEV,USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <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 eType 'of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> .:..�.,........:....-,�.-... .-_,,r..._: _.....-.....-z,-rte,--•�-.-.,.._,_�-- <br /> PUMP INSTALLATION: 4 Contractor <br /> 1 .1Type' of Pump H.P. <br /> PUMP REPLACEMENT: ' <br /> / / State Work. Done �.� , <br /> PUMP7BEPAIR: *'�_Rtate 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 r <br /> after completion of my work on a new well, :I will' furnish. the San .Joaquin Local Health District a N <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 ' 'GROUT INSPECTION <br /> PRIOR TO GR MIA INAL INSPECTION. <br /> E <br /> SIGNED &A& a i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)r <br /> .-FOR DEPARTMENT USE ONLY AV <br /> PHASE I _ <br /> APPLICATION_ACCEP-TED-»•BY-•--. "`7” <br /> ADDITIONAL COMMENTS: - '. ?; . i <br /> PHASE II GROUT INSPECTION PHA E INAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTION 'BY DATE —/ <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />