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Cow la�� � � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Foa OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone: '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/a <br /> 3 0.35, - -44;2:7 ���4_ ..,E!�, (Complete In Triplicate) - �`1_ o �f p�O / <br /> Application is hereby made to the San Joaquin Local Health District for a perinit to construct <br /> _and/or install the work herein described. This application is trade in compliance with San Jdaquin <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c� i� r: f CENSUS TRACT ' <br /> Owner's Name Par,P A.14.. US Phone ' <br /> Address T, Q 1 . <br /> City .S/ems+ Lla.�ra 64 <br /> Contractor's.Name ��`c�1�d License # �"-_�Phone 76 . <br /> TYPE OF WORK (Check):'.. NEW WELL /_" DEEPEN /? 'RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT / M <br /> Other L/ . . { <br /> w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 Driven Gauge of Casing <br /> _ W Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Sea1 'Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type `of Pump ✓ nU H.P. - SU <br /> PUMP REPLACEMENT: / / State Work Done,' ¢ <br /> PUMP REPAIR: 4 _ <br /> /� State Work Dorte ,• � ��J deoJ '� �^e ao <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> `Descfibe Material and.Procedure e <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 knowle and belief. I .WILL CALL FOR A 'GROUT INSPECTIONS ' <br /> PRIOR TO GROUTING AND A FINAL INSP <br /> SIGNED TITLE- <br /> W PL T PLAN ON ERSTE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL CommENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /%�-?6 <br /> E H 1426 Rev. 1-74 h/75 2M <br />