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SAN JOAQUIN� [�CAa HEALTH DISTRICT <br /> FOR,OFn' iCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. K <br /> f i Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date Issued -? <br /> .. (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 herei ► 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 /> JOB ADDRESS/LOCATION 2 v O S fj <br /> CENSUS TRACT <br /> Owner's Name , " Phare 35� <br /> -� 5 3 <br /> Address 3 l City , C € <br /> Contractor's Name . a <br /> License Phone,-'- <br /> Q1 <br /> TYPE OF WORK (Check): NEW WELL -LZ�'DEEPEN /? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION ,/—/ PUMP REPAIR /� PUMP REPLACEMENT <br /> Other E7 — <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIKES f PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER po . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL�� N ' <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIQNS �1 <br /> Industrial . ' f Cable Tool Dia. of Well Excavation <br /> Domestic/private 4 Drilled Dia. of Well Casing 2 77F <br /> Irrigtion Domestic/public Driven Gauge of Casing <br /> Irrigation - fL— <br /> g + Gravel Pack- Depth of Grout Seal t <br /> Cathodic Protection _ Rotary Type of Grout <br /> DisposalOther e <br /> Other Information9 ob _ f <br /> Geophysical Surface Seal Installed By: , i <br /> PUMP INSTALLATION: Contractor <br /> Type <br /> .of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> C7 State W 4 <br /> ork Done <br /> PUMP REPAIR i '�—f�S tdate-Work Done "} <br /> IES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District } <br /> and the State of California' peitaining 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 /> TELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.... The above <br /> InformaO GROUT GA F1tion is true to the bes <br />'RO' Tt--of- my knowledge and belief. ' I WILL CALL -FOR A 'GROUT INSPECTIO <br /> AL I N, <br /> iIGNED . <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HAS E I -------- s <br /> 4)PLICATION ACCEPTED BY <br />►DDIT.IONAL COMMENTS DATE ' & <br /> PHASE II-GROUT INSPECTION PHASE I INAL INSPECTION <br /> NSPECTION BY DATE -� 7 INSPECTION BY . <br /> ETH 1426 .. <br /> " DATE 2 9 -77 <br /> Rev. 1-74 <br />