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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA+OFFICE U %` 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. $� <br /> -; ._ 17!51--57311 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -/�- <br /> (Complete In Triplicate) i <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 grade 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 `fes- CENSUS TRACT <br /> Owner's Name �� tJ / Phone " <br /> Address 0. C.11�� <br /> y <br /> Cit <br /> Contractor's NameLicense j�4--X373PhoneA495ra6Jf'__ <br /> 1 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION 17 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TAN &�W,,EjR LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELI�" °'� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .,_ t/Domestic/private Drilled Dia. of Well Casing40 <br /> ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 'X Rotary Type of Grout r-7X/a �. /7"2F -�J <br /> Disposal m Other Other Information <br /> i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _-PUMP '.REPAIR: Work Done - <br /> ESIRUCTION OF WELL: Well Diameter Ja f Approximate De th l/ <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Loca fr t <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 my knowledge and belief. I WILL CALL FOR AmGROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE j <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE 0 LY <br /> PHASE I -• <br /> APPLICATION ACCEPTED BY,��a W14 G[ J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II f.ROUT, INSPECTION PHASE I J NAL SPECTION <br /> INSPECTION BY % 7 INSPECTION BY ATE 7 <br /> t E H 1426 Rev. 1-74 t 3-74 2M <br />