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SAN JOAQUIN LOCAL HEALTH--DISTRICT ' S <br /> FO "OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S-3D31� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-1� <br /> (Complete In Triplicate) <br /> Application is hereby 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 2 CENSUS TRAGI <br /> Owner's Name <br /> Phone ' <br /> Address City <br /> �2 <br /> Contractor's Name License # x(02 Phone, G.Z-�'S�7 + <br /> k <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_7 RECONDITION DESTRUCTION f f w <br /> PUMP I5�ALLATIf�N. / / PUMP- REPAIR -L-7-p'UMP REPLACEMENT /7 <br /> i Otlietc /7 --- <br /> Y �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE -_ PRIVATE DOMESTIC WELL PUBLIC•DOMESTIC WELL C11 <br /> INTENDED. USE TYPE OF WELL A CONSTRUCTION SPECIFICATIONS q� <br /> Industrial ' I Cable Tool Dia.-of Well Excavation I <br /> Domestic/private -' Drilled Dia. of We11 Casing <br /> Domestic/public DrivenE <br /> Gauge of Casing <br /> Irrigation s Gravel Pack Depth of Grout Seal" <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal i Other Other Informatiozi— <br /> Geophysical Surface Seal Installed �B .:- <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump ' <br /> - - .. H.P. <br /> PUMP REPLACEMENT: / State Work Done ~� <br /> PUMPIREPAIR: <br /> St�te Work Done . . . f7 <br /> i <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> C hereby- agree to comply with al haws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well 'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />►TELL DRILLERS REPORT of the well and notify them before putting. the..well, in.use.... The above ,: <br />_nformation is true to the bestj$ my knowledge and belief. I' WILO PALL FOR 'A GROUT INSPECTION <br /> RIOR TO GRO LING AND A I ECTIO <br /> 1IGNED <br /> TITLE <br /> DRAW P PLAN ON REVERSE SIDE <br />'RASE I 7 'FOI;�DEPARTNENT VSE ONLY <br /> PPL A'ION ACCEPTED B - <br /> IDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> PHASEj_ W F NAL INSPECTION <br /> NSPECTION BY DATE INSPECTION EYr DATE �}J S� <br /> E H 1426 Rev. 1-74 �..r .-_ A <br />