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{ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FoR•iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7KC- 3 <br /> 76_9gs'P <br /> THIS PERMIT „%P.IRES_l YEAR_F'R_OM:RTE ISSUED Date Issued <br /> {, {Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health bi.6trict for a permit to construct <br /> and/or install the work .herein described. , This application-is made in compliance with San Joaquit <br /> E County Ordinance No. 1862 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U • { �'t}C C CENSUS'TRACT <br /> Owner's NameQ 6e �-e� Phone <br /> Address (.a City . <br /> Gontractox's Name _{,e,tTLTe A1U.4CiC License #,1007fy Phone <br /> TYPE.OFI WORK (Check): `-NEW WELL ,f r DEEPEN /_� kgCONDITION17TDESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT f7 <br /> Other '- ► <br /> DISTANCE,'TO NEAREST:,-e. SEWER LINES 400 PIT PRIVY <br /> SEWAGE DISP SO AL 7IELD CESSPOOL/SEEPAGE PIT-z �' OTHER <br /> _ 1 PROPERTYa EINES PRIVATE—DOMES-TIC WELL PUBLIC DOMESTIC WELL <br /> r <br /> • INTENDED USE TYPE OF WELL; CONSTRUCTION SPECIFICATIONS — T <br /> Industrials ' 3 F ,Cable Tool Dia. ofWe11 Excavation �"!_ <br /> - <br /> ^ Domestic/private *Drilled D1a:..of;Well Casing <br /> Domestic/public i. Driven Gauge of 'Casing .Cf oir 16 6 --- <br /> Irrigation , . ldiivel.Pack Depth. of Grout Seal <br /> Cathodic Protection RC -Rotar'y Type of .Grout ___ _ 51 <br /> Disposal - Y Other Other Information <br /> GeopLWai.ca3 .� Su`r'face Seal Installed,BY: <br /> PUMP INSTALLATION: Contractor aX. <br /> Type of Pump H.P. <br /> 1e <br /> PUMP REPLACEMENT: p/ S tate Work Done �� Q off] T6 e <br /> PUMP .REPAIR: 7. State WorkLDo`ne - <br /> PE&TTRUCTION OF WELL: Well Diameter a Approximate Depth _Q00 � <br /> Describe Material and Procedure 77) A c <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 Sari 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 GROUMGAND A FINAL INSPECT,10N. <br /> SIGNED TITLE <br /> + W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> 4 APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> E PHASE II 0 T NSPECTION - PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE, V INSPECTION• BY •' DATE <br /> c <br /> E H 1426* Rev. 1-74 _ _ _ 1-74 2M <br />