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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FO$iOFF'ICE USE: , / 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 711- ' <br /> A <br /> hiIS PERMIT EXPIRES -1-YEAR FROM DATE ISSUED Date Issued 6�7y <br /> (Complete In Triplicate) <br /> Application is hereby made!"to the San Joaquin Local .Health District fora permit to construct <br /> and/or install the work het6in described. This application is made in compliance with San Joaquij <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ g 3 O pct., CENSUS TRACT <br /> Owner's Name �'ct40 Phone <br /> Address r - f� - ,_�;Y� City " <br /> Contractor's Name v�cu�aa�/ !z� License # 4W>--hone V6Y 67.� <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN /� RECONDITION /_� DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR /, I 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 WELT. PUBLIC DOMESTIC WELL <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing f <br /> Domestic/public i Driven Gauge of Casing <br /> k�)4- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> i Disposal :- Other Other-Information=• s <br /> r Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' j m w. <br /> - Type of Pump - H.P. <br /> PIMP REPLACEMENT: Ll State Work Done <br /> PUMP '.REPAIR: State Work DonefZ <br /> /k ce /A��rjf",a'�aa �ff� 4y r <br /> 2ES;TRUCT_I.ON- 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 tha well and notify them before putting-the.-well in use.. . The above <br /> information is true to the''best of my kno a gond lief. I WILL. CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT ON. <br /> SIGNED LE / , <br /> ( PLOT LAN ON REVERSE SIDE <br /> FOR DAPARTMENT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY .__.4 DATE r� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II INSPECT ON <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> 'i > 1 E H 1426 Rev. 1-74 1-74 2M <br />