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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �j_1-2 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION ©FJ S CENSUS TRACT <br /> Y <br /> Owner's Name v �" Phone34-75--o�g 7 7 <br /> Address <br /> JuL. /t/C� P �1Ta G�77J� City <br /> Contractor's Name ICj License #Sct)3ZPhone <br /> TYPE OF WORK (Check) : NEW WELL '/P171" <br /> DEEPEN /_/ �RECONDITION _DESTRUCTIONT <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEhbPRIVATE DOMESTIC WELL&�-50 PUBLIC DOMESTIC WELL (� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q. <br /> Industrial Cable Tool Dia, of Well Excavation 'r <br /> D6mes,tic/private Drilled Dia, of Well Casing /D <br /> Domestic/public Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal � Ho k` <br /> Cathodic Protection X _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INS1TALLATION: Contractor m /'Uv'�.� - M^Jo*,� 1 Gvv�. <br /> �i Type of Pump - H.P. . . O <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR.:--- State Work Done <br /> I <br /> DESTRUCTION OF WELL;:.. Well Diameter Approximate Depth <br /> Describe Material and Procedure s <br /> r • <br /> �r <br /> I hereby agree to comply with all laws and regulations, of the. San Joaquin Local Health District <br /> and the State.rof California pertaining to or regulal�.ng: well 'construction. Within FIFTEEN DAYS <br /> after completion of�jmy 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 /> , <br /> information.is. .t'rue-to the Aest of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT, 7 A L NSPECTION. <br /> SIGNED TITLE ---.42 Cu <br /> fLZZ (DRAW PLOT PLAN ON REVERSE SIDE) - - <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC N PSE414I/FI.IJAL INSPECTION <br /> INSPECTION BY DATE Z11 Itr INSPECTION BY ;'A DATE <br /> ,. ay 7 { l 1/7.7 <br /> E H 1 Rev. 1-74 �• rw. <br />