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i 6o A4` 1 SAN ;JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOHfO F CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t 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 <br /> (Complete In Triplicate) l ^-0 yo- p <br /> Application is hereby made to the Salt Joaquin Local, iiealth District for a permit to construct <br /> and/or install the work herein described. This application is trade in compliance with San Joaquin <br /> Cou ty Ordinance No. 1862 •and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION12 <br /> 3 A, 0 6// 14V CENSUS TRACT <br /> Owner's Name u✓ Phone <br /> Y + <br /> Address / .0,,>Z _ City ��A ori _/C- <br /> ' Contractor's Name md/ tt." Z License # l 37A­�PhoneA 74 <br /> E <br /> TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN -/-7 RECONDITION /? DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR & PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWMR LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELI: <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private. Drilled ' Dia. of Well Casing <br /> Domestic/public+ DrivenA Gauge of Casing r. <br /> Irrigation - f -Gravel Pack Depth of Grout Seal <br /> Cathodic Protecfton Rotary Type of Grout <br /> Disposal Other Other Information V <br /> Geophysical:` °' Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor . p <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT: / / State Work Done �. <br /> PUMP '.REPAIR: -;Z' State Work Done . <br /> ES;'RUCTION 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 the well and notify them before putting the -well in-use.. The above <br /> information is true to the best of my owls e d belief. I WILL. CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL I I `_ 1 <br /> SIGNS TITLE <br /> ( W LO PLAN ON MRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II "GROUT INSPECTION RASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY b.r a A)ATE <br /> �1 E H 1426 Rev. 1-74 1-74 2M <br />