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=. rs SAN JOAQUIN LOCAL HEALTH. DISTRICT y f� <br /> FOF: OFFICE USE: ij 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedD�7 7 <br /> A, �': (Complete In Triplicate) <br /> ! Applica-tion is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/o="install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance Na. 1862 and the Rules-and egulati of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> t <br /> Owner's Name ii Phone -- <br /> Address a Cit <br /> -� .-. i:.f y w,.,.... <br /> A � <br /> FContractor's ;Name _ S � License its - 0 'P'hone <br /> TYPE OF WORK (;'(Check) : NEW WELL '/—/ DEEPEN /_/ RECONDITION /_� DESTRUCTION /� <br /> �� PUMP INSTALLATION _/V PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other! / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE{DISPOSAL FIELD CESSPOOL/SEEPAGE`PIT OTHER <br /> I PROPERTY LINE, -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL w�j CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool A JV J Dia. of Well Excavation <br /> Domestic/private Drilled4,�lDia. 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 #Y Other Information. <br /> i Geophysical ! Surf ace SeallInstalled By: <br /> T , _77J <br /> PUMP INSTALLATION: Contractor <br /> 11 Type of Pump / ,. H.P. <br /> PUMP REPLACEMENT: / / State Work Done J <br /> PUMP .REPAIR: /_ . State Work Done �...,, . <br /> DESjRUCTIONOFOFIWELL! Well Diameter 'e.,,_,Approximate Depth <br /> Describe Material and ProcedurJel 1 J I W .I hereby agree to comply with.all laws and xegulationsJof, the San Joaquin Local Health District <br /> A, <br /> and the State of California pertaining to or regulatingi,welli,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 GROUT G AND A YAM IiaSPWrION. <br /> S_IG N_ED r TITLE <br /> -" - -.�(-DRAW_PLOT_ELAN--0N,7REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;' <br /> APPLICATION ACCEPTED B " DATE <br /> ; ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III./FINAL INSPECTION <br /> INSPECTION BY DATE Al , - INSPECTION BY � ATE H_2`z��� <br /> 77 " 2Ni <br /> E H 1426 # Rav_ 1-71L _ <br />