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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 'Permit No. 7wl, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED *;Date Issued <br /> (Complete In Triplicate) 2_6 f -too- 03 F <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 /> Coun!_�y Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION <br /> T LS <br /> I • 6 CENSUVTRACT , <br /> Owner's Name / rrj P o P rvc`A RLPtione ' <br /> .t. <br /> AddressfU <br /> Da city <br /> Contractor's Name. <br /> License U Phone � -Z- 6,1 Y7 <br /> 9 <br /> TYPE OF WORK (Check): NEW WELL -L-7 DEEPEN RECONDITION /? DESTRUCTION /7a <br /> Y PUMP INSTALLATION/ / PUMP 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 Tooh. 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 r'—` . . . <br /> Surface Seal Installed 'By , .r <br /> PUMP INSTALLATION Contractor <br /> Type of Pump - H.P. r . <br /> PUMP REPLACEMENT / / State Work Done <br /> PmREPAIR: / / State Work Done ; <br /> fESTRUCTION OF .WELL: Well Diameter 1� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply.wi.th-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 FORA GROUT INSPECTION <br />?RIOR T� 4 <br /> ED eA�IAL�'SP�ECTIO�N. <br /> SIGNED T TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE [j -7(9 <br /> UDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE cR -/�{"'? <br /> E H 1426 _LLRev. 1-74 ;- 117,5 2M <br />