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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. ' Stockton, Calif. <br /> �I Telephone: (209) 466-6781 <br /> �I APPLICATION FOR WELL CONSTRUCTION OR PUMP1 PERMIT Permit No. 7-„�� <br /> `il <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_ 4. <br /> . . 72 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .0'4ZI Af <br /> CENSUS TRACT <br /> Owner's Namp4p� Phone <br /> Addx� 1 j Q e 73& k 7z- IEP� Cit <br /> y <br /> Contractor's NameT� CJ License iG�a�Phone4��g� ��. <br /> TYPE OF WORK (Cbieck) : NEW WELL /7_DEEPEN^/ / RECONDITION /_7 DESTRUCTION /_7 <br /> II PUMP INSTALLATION '/ ./ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other I / <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6 PIT PRIVY <br /> SEWAGE DISPOSAL_ FIELD CESSPOOL/SEEPAGE PIT 4 OTHER{ <br /> !!� PROPERTY LINE PRIVATE DOMESTIC WELL PUB I , <br /> L C DOMESTIC ML . <br /> INTENDED ,:USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool,- Dia. of Well. Excavation <br /> 1�. 'Domestic'/,private Drilled Dia.iof. 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 R - s <br /> Geophysical Surface Seal Insta <br /> PUMP INSTALLATION: <br /> Contractor <br /> a Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / /, ,,S.tate -Work Done _ <br /> PUMP„REPAIR: 1,.I�p . / / :,State-Work Done <br /> DESTRUCTION OF WELL: - Well Diameter <br /> Approximate Depth ; <br /> Describe Material and Procedure "”' <br /> I hereby agree to 'comply with all laws and regulations of the San Joaquin Local Health Dlatrict <br /> and the State of California 'pertaining to or regulating well 'construction. Within FI9T$TM Ditg <br /> after completid0.a of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> information is .true to the best of my knowledge and belief. z WILL CALL FOR A GROUT INSPLCTI(?4. <br /> PRIOR TO GROUTING AND A-FINAL INSPECTION. � <br /> SIGNED �F TITLE <br /> s� <br /> D yd: PLAN 'ON REVERSE SIDE °"I;,' <br /> R DEPAR T USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPT BY � A DATE - '�Z , <br /> ADDITIONAL COMM$NTS: <br /> PHASE II GROAT INSPECTION PHASE III FINAL INSPECTION', <br /> INSPECTIQN BY _�, DATE INSPECTION BY 4 DATE /,2- <br /> E H 1426 Rev. 1. 74 V76 2M <br />