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�Y SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT <br /> F0&.-,OFFICE USE; 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone.; (209) 466--6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71° <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED' Date Issued6 <br /> (Complete In Triplicate) 224p--tla- 2,2 <br /> Application is hereby' made ..to the San Joaquin I.ncel health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with Sari Joa�'U <br /> County Ordinance No. 1.862 an6 the Rules and ulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION <br /> ON f <br /> PP <br /> C� sUS TRACT <br />'. Owner's Name a * � Ly 'D _ S <br /> Address 3�a( cl6 � City . . . �C_//z d <br /> Contractor's Name License ! Phone <br /> TYPE OF WORK (Check) : "NEW WELL /_7 DEEPEN 17 RECONDITION /-7- DESTRUCTION--fg --_ <br /> -* _m. �- �" PUMP'"INSTALLATION PUMP REPAIR'/� PUMP REPLACEMENT j f <br /> Other !/% <br /> DISTANCE TO NEAREST; SEPTIC TANK /o y SEWER,LINES PIT PRIVY <br /> SEWAGEDISPOSAL ,FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY`._LINE"toPRIyATE.DONESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ._TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation . i <br /> Aoinestic/private i Drilled--, Dia. of Well Casing <br /> Domestic/public F Driven Gauge of Casing ' <br /> Irrition Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal 4 Other _ Other Information <br /> sical <br /> Geophy #: Surface Seal 'Installed 'B ; <br /> PUMP INSTALLATION: <br /> • Contactor <br /> € Type; of Pump <br /> PUMP REPLACEMENT: . --- - '- . - -�},`i-+, . a } � - � �•P. � <br /> State Work Done'l- <br /> F � r <br /> PUMP `REPAIR; State Work Done <br /> �V <br /> DESTRUCTION OF WELL; Well'Diameter. APP ox $te Depth - <br /> Describe Materia]: and Pro-cedue-- k <br /> 7. <br /> I hereby agree to comply with all laws and regulatiions of the -San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well,"construction. Within FIFTEEN DAYS a <br /> after completion of my work'on a new we1l, !I willEfurnish the San Joaquin Local. Health District a i <br /> WELL DRILLERS REPORT: of .the =w.611 and notify them before putting. the.,well in use.... I'The above <br /> information is true to-the best of,my.knowledge aiid-_belief.. ;I_-WILL CALL- FOR--A- GROUT-INSPECTION <br /> PRIOR-TO-GROUTTM AND-,*-I'1 ._.: - TION; <br /> SIGNED <br /> (DRTITLE— <br /> AW PLOT PLAN ON REVERSE SIDE) ""- <br /> f I <br /> PHASE F DEPARTMENT USE ONLY <br /> -- � � � _ .1.... v- <br /> APPAPPLICATIONICATION ACCEPTED.,.}-BY" <br /> DATEsl�4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAIV INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> E H 1426 Rev. 1-74 r. ... 1.A7 <br />