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f <br /> SAN JOAQUIN DOCAL"HEALTH DISTRICT <br /> —0 .OFFICE USE: 1601 E. Hazelton"Ave'.', Stockton, Calif. y <br /> Telephone*.,z 1--,(209) 46.667_'81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _.),4&j <br /> I} <br /> THIS,'PERMIT $EXPIRES 1,.YEAR' FROM,,DATE'.bISSUED o Date Issued <br /> Application is hereby made to the San Joaquin.<Local ;Realth •Di.atrict`:;for a°permit sto construct <br /> and/or,:install ,the work herein described -r ,This rapplicat.ibn,,is made.-ini compliance with-SAn Joaquin <br /> County ordinance No '-1862.�and the_-Rules,,and -Regulations'.1.of,.the:.San-:Joaquin t.Local"Health Distiiet. <br /> G /(_ 4�7� ' CENSUS'TRACT ADDRESS/LOCATION <br /> S <br /> Y . P a.R P T 9 _ r". a, e1(..d ry:+i ...}'• �S ;.� .1 ,.o-+ 0...A v- 'e-d,. S f..,y 5 �_.Y;� .L�.• '.,,r"Y4 -. � .n �.i _yc`3..9, I f.'.4R - F. b <br /> -... - <br /> Ownei s s 1 amie"` <br /> .aa [j cry Phone <br /> City .w �........�. . .,.m.. ..,.. <br /> Address XV, <br /> - . License - Phone �0 <br /> Contractorls.Name <br /> TYPE OF WORK (Check): ' 'NEW WELL /; �"bEEPEN; / 7 RECONDITION '/� ' DESTRUCTION, <br /> ' PUMP INSTALLATION / PUMP REPAIR /_/ PUMP REPLACEMENT ./— <br /> 3 . x Other <br /> DISTANCE TO NEAREST. rSEPTIC TANK , SEWER LINES ; PIT PRIVY a <br /> * ' OSSEWAGE DTSPA�L FIELD ""CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' `' PUBLIC:DOMESTIC WELL <br /> -,INTENDED USE. TYPE OF WELL <br /> 'CONSTRUCTION: SPECIFICATIONS <br /> i industrial: L- ' able Tool Di.a. ,of Well Excavation <br /> L--'Somestic/private Drilled Dia. '.of Well Casing <br /> Domestic/publicl s ;Driven4 Gauge of Casing <br /> s Irrigation ;. Gravel, Pack t Depth of Grout Seal <br /> s Cathodic Pr_otectfan ,'Rotary: Type of Grout <br /> I Disposal Other Other Information <br /> .,.. <br /> Geophysical Surface Sea] Installed B <br /> f �2 . <br /> PUMP INSTALLATION: . Contractor <br /> Type of :Pump H.P. " <br /> State Wont Done <br /> PUMP REPLACEMENT: / °% 6 ' , <br /> } __.. <br /> PUMP ,.REPAIR: . /�' � State Work Done } <br /> XS'.T]iUCTION OF WELL:: Well Diameter Approximate Depth <br /> 7' Describe Material'and Procedure <br /> I Hereby agree to comply with all laws:and regulations of the SaniJoaquin Local Health District <br /> and, the State of California pertaining to •or'regulat•ing '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." TWILL' CALL FORA GROUT INSPECTION <br /> PRIOR TO GROU NG DA FIN SPECTION.. . _ <br /> SIGNED TITLE <br /> i - (DRAW PLOT ,PLAN`ON REVERSE.SID <br /> ;. <br /> �.FOR.DEPARTMENT USE ONLY <br /> PHASE I k <br /> APPLICATION ACCEPTED"BY ' `, DATE 116S <br /> I ADDITIONAL COMMENTS:.. <br /> 'PHASE 'II GROUT INSPECTION PHASE III FINAL INSPECTIO4, , <br /> INSPECTION BY DATE INSPECTION BY y DATE <br /> k 1 r „E H 1426 Rev, 1-74 -74 2M. <br /> ' 1 <br />