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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: 1601 E. Hazelton Ave, , Stockton Calif. <br /> Telephone: (200) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED Date Issued 77- <br /> Sa <br /> (Complete 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 rade 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/hOCAT ON �Z 5.2 ylj atL6 CENSUS TRACT <br /> Owner's Name Phone ' ?3,?- <br /> Address fScl City <br /> i Contractor's Name 'License #a f 245' Phone <br />} <br /> TYPE W;� ORK -(Check) : NEW WELL.,H DEEPEN '/? RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION �/ PUMP REPAIR '/ PUMP REPLACEMENT /7 <br /> Other / / --•- <br /> F DISTANCE TO NEAREST: SEPTIC TANK /d7,5- SEWER LIN�:S PTT PRIVY <br /> SEWAGE DISPOSAL FIELD 105- CESSPOOL/SEEPAGE PITS _� OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /Z.7—­ <br /> Domestic/private Drilled Dia. of Well Casing p <br /> -`Domestic/public Driven Gauge of Casing .2, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout ' 0A. 17 -' <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed 'B du/ •�� <br /> PUMP INSTALLATION: <br />. ConCractbr .E.�Bf:�G � lvf�.�-T. <br /> Type of Pump H.P. <br /> F PUMP REPLACEMENT / / State Work Done 4 <br /> PUMP '.REPAIR: / / State Work .Done <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth S ; <br /> Describe Material and Procedu a '�- <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 /> ofer completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL PORT of the w 1 and notify them before putting.the..well. in .use-. . .The above <br /> ir; zma on is true to the-b t-of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR GROU N AN I INSPECTION- <br /> SIGNED <br /> NSPECT N.SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7'7 <br /> ADDITIONAL- COMMENTS: T3,404m— <br /> P I RO INSPECTION P II3 N INSPECTIO <br /> INSPECT3ON BY Y?ATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �r 1./75 9 <br />