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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 9atOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5 <br /> ;I <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issue 4,91774 <br /> (Complete In Triplicate) i <br /> Appii6dtion is hereby made toIthe San Joaquin Local Health bisttict 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 G Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION � i L ' CENSUS TRACT <br /> ,f s <br /> Owner R s Name 1\o L _ Phone <br /> Address �� _.� City <br /> Contractor's Name CL <br /> ( ' I� :1 L 1k 1 �. �6 License # 6 6 OZ Phone �ar� <br /> t i <br /> a <br /> TYPE OF WORK (Check); NEW WELL / DEEPEN/� RECONDITION /� DESTRUCTION f-T <br /> PUNK' INST LATION / / PUMP REPAIR I / PUMP REPLACEMENT /7 ti <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE t TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Ilia. of Well Excavation ' <br /> Domestic/private i i Drilled ..k' Dia. of Well Casing <br /> Domestic/public _ ' - $ g - -• _ ' <br /> :ry i��Driben Gau a- ,of Casing / ... <br /> Irrigation " Gravel Pack Depth of4Grout Seal 3"6' <br /> Cathodic Protection. Rotary A Type of Grout E> 2&2I TO _ <br /> Disposal Other- 4 ,�, ° Other Information " <br /> Geophysical . t£ ­�Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .j <br /> Type Of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done a °a- <br /> PUMP :REPAIR: / State Work Done - �- <br /> PE&T RUCTION OF WELL: We11 .Diameter '"� Approximate .Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all:3aws,rand. regdla:tions_of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> h after completion of my work on a new well, 141ll-fijrnish the San Joaquin Local Health District a <br /> WELL DRILLERS/REPORT of the well and notify them^before puttng..the..well in use.. The above <br /> information is true to the-best of- my knowledge andbelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UT NG ANU F_ •NAL INSPECTION. <br /> SIGNED TITLE <br /> ^' (DRAW PLOT PLAN ON REVERSE SIDE <br /> _, --- FOR DEPARTMENT USE3ONLY - <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f <br /> .-.._—_PHASE -II-GROUT INSPECTION PHA5E III FI INSPECTIO <br /> INSPECTION BY- DATE INSPECTION BY _DATE 9 G 75' <br /> E H 1426 Rev. 1-74 1-74 2M-. <br />