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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FO. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -2 <br /> r It Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -2 ?-317W <br /> i <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued ' i <br /> 11 (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 /> County Ordinance No. 1862 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> .FOB ADDRESS/LOCATION �f�lG-�� CENSUS TRACT r <br /> Owner's Name ke- Phone <br /> Address j ./ �1 - c <br /> f. <br /> City C�J <br /> Contractor's Name <br /> �c.� ,7 License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR '/—/ PUMP REPLACEMENT /-J <br /> Other , % # <br /> DISTANCE TO NEAREST: SEPTIC '.TANK SEWER LINES PIT PRIVY _ <br /> SEWAGEIDISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE_ RIVATE DOMESTIC WELL �11 PUBLIC DOMESTIC WELLi <br /> INTENDED,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable 'Tool Dia. of, We11 Excavation <br /> Domestic/private II Drilled Dia. of. Well Casing �r <br /> Domestic/public it Driven Gauge of Casing <br /> Irrigation <br /> g it Gravel Pack. Depth of Grout- Seal � <br /> Cathodic Protection i1 Rotary £Type of Grout <br /> Disposal <br /> ;4 Other .-Other-Information i <br /> Geophysical Surface Seal Installed By: /iZ.�. <br /> PUMP INSTALLATION. Contractor r <br /> 4 <br /> + � <br /> Type cf Pump r s H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: - -'-/,--/--State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe PP P <br /> Material and Procedure ' <br /> I hereby agree to comply withl.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 mywork on a new well, I will furnish.-the San Joaquin Local Health District a <br /> WELL DRILLERS 'REPORT- --th .well and notify them before putting the ,well in use. The above <br /> information is t to the-bes my kn wledge and belief. I .WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AL INSPE <br /> SIGNED TITLE <br /> (DRAWs MVPLAN 'ON RE -ERSE.N.SID i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE­I ' <br /> tt <br /> APPLICATION ACCEPTED BY1 TE 3- Dq--7 } <br /> ADDITIONAL. COMMENTS: . � <br /> PHAS OUT INSPECTION P S AL INSPECTION <br /> INSPECTION BY DATE �L INSPECTION BYj DATE <br /> E H '1426Rev. 1-74 376 2M = <br />