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ay <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-�;/1,?13 <br /> T14TS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> II (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 made in compliance. with San Joaquin <br /> 1 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 'rno Phone <br /> Addr dl s E, iQ S City -came <br /> Contractor's Name J[ e1 c a�`� ,License} #3ML3 Phone <br /> ! . . - i <br /> TYPE -,jOF WORK (Check) : NEW WELL IK DEEPEN /_/ RECONDITION /_-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Otherl/ / <br /> .DISTANCE TO NEAREST: SEPTIC TANK _0♦ SEWER LINES - PIT PRIVY <br />{ SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE fi TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> , Industrial1Cable Tool Dia. of Well Excavation �i <br /> JDomestic/private F Drilled Dia. of Well Casing <br /> , Domestic/public 1 Driven Gauge of Casing <br /> (:Irrigation Gravel Pack Depth of Grout Seal <br /> i kathodic Protection 1 y Rotary Type of Grout ° Aelvm <br /> Disposal .r ITT Other Other Information <br /> J#Geophysical' Surface Seal Installed,' B : <br /> PUMP INSTALLATIONeo + I <br /> C ntractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done. k! <br /> t: BGG <br /> PUMP REPAIR: / / � State�Work'Done <br /> DES-TRU�CTION OF WELL: Well., Diameter Approximate Depth <br /> Describe,,.. and Procedure . <br /> -, l <br /> I herby agree to comply with all laws and regula`tloris of the San Joaquin Local Health District <br /> and the State of California=pertaining to or regulating well ''construction. Within FIFTEEN DAy.S <br /> after completion of my work an anew=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 true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AN A F INSPE N. ; <br /> SIGNED - TITLE <br /> 1 (DRAW. PLOT PLAN-ON-REVERSE SIDE <br /> PHASEIII OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY # D? 14-� I DATE 7 /-7//-71? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL ANSPE TI N <br /> INSPECTION BY DATE INSPECTION BY4.�.--- DATE s�•-��' <br /> k Eli 1426 Rev. 1-74 _ �- - 117.7 - ' 2M <br />