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SAN JOAQUIN LOCAL.HEALTH DISTRICT � <br /> T'OF�1OFFICE USE: 1601 E. Hazelton Ave. ,-Stockton, Calif. 1 <br /> Telephone (209) 466=6781 ¢ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl-yf?p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applieation is hereby .-Wade to the Salt Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and.Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION &/ 40r �� �-�C�1� ��7` CENSUS TRACT p <br /> Owner's Name .~�-1 Phone -��" � 7 0 6 <br /> 6/7 I <br /> Address 7 � ` City J' �s <br /> Contractor's Name1 %— 1//- <br /> License i� Phone <br /> TYPE OF WORK (Check)..- NEW WELL /-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / P REPAIR /- PUMP REPLACEMENT 17 <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 Cable Tooi Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �! <br /> -. Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump HSP. <br /> 4 <br /> PUMP REPLACEMENT: State Work Done ._ 1 <br /> ---�-^/ / =-State-Work Done -•- M. _.� - - =— x�-= . <br /> .PUMP:!REPAIR.::�- � _ . <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> 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..well in use.. The above <br /> information is true to the best-of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � x <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> ~E H 1426 Rev. 1-74 1-74 2M ; <br /> -.- <br /> 0 <br />