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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fOr: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 J 7-4��2-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -"-,3- 72 <br /> (Complete In <br /> Application is hereby made to the San J aquinr <br /> Local for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin II <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. 1 <br /> I <br /> JOB ADDRESS/LOCATION "7 Q ! <br /> 7�� w CENSUS TRACT # <br /> Owner's Name <br /> e.0 Al <br /> Phone <br /> Address 3M.4.,,t, <br /> City � cs�:- � <br /> Contractor's Name s* ZAJ License #1 phone <br /> TYPE OF WORK (Check) ; NEW WELL /d - DEEPEN/_% RECONDITION /-7 DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES // 15 PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC ME <br /> DOSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 :Cable Tool Dia, of Well Excavation <br /> Domestic .�� \� <br />�_�� /private Drilled Dia, of Well Casing � V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ��M��� <br /> Other Information <br /> Geophysical Surface Sea]. Installed B + <br /> r <br /> PUMP INSTALLATION: Contractor � �� � <br /> Type of Pump `a e • �6 5 76 <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .ItEPAI: / / State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter*- <br /> Describe Materia]. and Procedure Approximate Depth <br /> C 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 /> BELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> Lnformation is true to the best of myknowledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br />)IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> e <br /> j., <br /> FOR DEPARTMENT USE ONLY <br />'RASE I " <br /> YPLICATION ACCEPTED B41A DATE �-- <br />,DDITIONAL COMMENTS: <br /> PHASE I I S ECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY TE INSPECTION BY DATE /x . e- 77 <br /> E H 1426 Rev. .1-74 1177 - 2M i <br />