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SAN JOAQUIN LOCAL HEALTH,,DISTRICT <br /> FO£s OFFICE USE: 1601.E„aHaaelton-Ave:=r-Stdckton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7G_ 71Zi fes' <br /> THIS PERMIT EXPIRES 1 YEAR FROM..DATE ISSUED Date Issued g-la <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District. for a permit to construct <br /> and/or instal, the work herein described. This application is made -incompliance with,San •Joaquin <br /> County Ordinance No. 1862 'ind the Rules and Regulations of the San Jogqu3n ,Loca1 Health. District. <br /> JOB ADDRESS/LOCATION l/ Q ' OO CENSUS. TRACT <br /> Owner'g'N'ame /I-tAPhonefw <br /> Address L1 e/p - city <br /> Contractor's Name Licensee �Y�_Ahone <br /> i <br /> TYPE OF WORK (Check): NEW WELL j DEEPEN 'j CONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATIONN/ PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Tool Dia'. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> ligation —.Gravel Pack Depth of Groat Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br />' —Geophysical Surface Seal: Installed B .� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br />' P PAIR: / / State Work Done <br />•DESMON OF WELL: Well Diameter Approximate Depth <br /> Describe i4aterial and Procedure <br />�j hereby ,agree to comply with all laws and regulations of the San Joaquin Local Health District , <br />''#nd 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 /> WELL DRILLERS REPORT of the well and notify them before,putting..the..we'il.•..inruse.:.. The above ' <br /> information.is true to the.best ,of. my knowledge%land'belief. f WILL CALL FOIL A.,GROUT INSPECTION <br /> PRION GROUTI D A VIN � PE.CTXON. 1_-i <br /> SIGNED — — .. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4 <br /> P GROUT INSPECTION PHASE III/FINAL INSPECTIN � <br /> INSPECTION BY DATE INSPECTION-BYDATE a <br /> E H 1426 Rev. 1-74 ! ' 4/75 IN <br />