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SAN JOAQUIN LOCAL TIEALTH DISTRICT � <br /> FOArOF ICE USE: 1601 E. Hazelton Ave.:`, 'Stockton, Calif. i <br /> Telephone: (Z09)' 466-6781 1,� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:7 - Y,13 le f <br /> t <br /> THIS PERMIT EXPIRES l-YEAR.4ROM DATE ISSUED Date Issued 3 <br /> i <br /> (Completet.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 /> j . 7? <br /> JOB ADDRESS/LOCATION. _CjriA dcvCENSU$ TRACT <br /> Owner's Name Phone <br /> Addres6m City <br /> Contractor's NameCSARk� <br /> License # , 7�„� '$Zione _ 67--?d <br /> A 4 � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL -/- DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATIONPUMP REPAIR / j PUMP REPLACEMENT17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESt --- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I , <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 j <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> { <br /> PUMP INSTALLATION: Contractor ; <br /> Type. of Pump ✓ If H.P. <br /> 3d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ! /)r7 State Work Done <br /> ES;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 /> 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 mw know dg belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A. FINAL INS 07)7 <br /> SIGNEDITLE <br /> (D LOT PLAN ON REVSRSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I 3 y <br /> APPLICATION ACCEPTED BY DATE O ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TI N PHASE ZFfjFjN&jNSPECTION <br /> INSPECTION BY DATE INSPECTION- BY ATE <br /> s <br /> ~E H 1426 Rev. 1-74 1-74 2M <br />