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t� <br /> �APPLICATION <br /> 71, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O%n OFFICE USE: 1601 E. Hazelton Ave. , Stockton,,.Calif. <br /> Telephone: (209) 466-6781 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -�\0-11},w <br /> : THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L y <br /> (Complete In Triplicate) D -/3 0 34 <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or install the worst herein described. This application is wade in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JO - <br /> B ADDRESS/LOCATION ` -. -� CENSUS TRACT <br /> i <br /> Owner's Name d� Phone 51d- �7 e' <br /> � t - <br /> Address City <br /> � t <br /> Contractor's Name d° License Phonej&/p ?' ---,� <br /> TYPE OF WORK (Check): NEW WELL / EEPEN '/ RECONDITION /-7DESTRUCTION _/ <br /> PUMP INSTALLATION / UMP REPAIR 1—/ PUMP REPLACEMENT 17 -� <br /> ` Other /—/ <br /> I ___ V? <br /> DISTANCE TO NEAREST: SEPTIC TANK PO SEWER LINES l IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER Z <br /> _ - I WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE PROPER EINO���IVATE-DOMESTIC. _,..,,.,,. <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial fable. Tool Dia. of Well Excavation <br /> mastic/private Drilled Dia. of Well Casing' <br /> Domestic/public Driven Gauge of Casing l,7 <br /> Irrigation Gravel Pack Depth of Grout Seal $� <br /> ' Cathodic Protection Rotary Type of Grout' .$ 4 <br /> = Disposal Other Other Information <br /> k Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor , <br /> Type: of Pump lop H.P./ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /7� State Work Done . -- <br /> E&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 /> WELT. DRILLERS REPORT of the well and notify them before putting.the..well in-use. The above <br /> I information is. true to the-beat of my.knowledge and belief. I WILL CALL FORA-GROUT INSPECTION <br /> PRIOR TO GRWTIW AND A FI INSPECTION. <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE .1 ? <br /> APPLICATION ACCEPTED BY � `j DATE <br /> ADDITIONAL COMMENTS: <br /> E _ PHASE II GROUT INSPECTION PHASE III/FXNAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />