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Ce m `aSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh 0 FICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. ' <br /> Telephone : . (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-3757P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /4/--z 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari 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 /> f� <br /> JOB ADDRESS/LOCATION MLe�.6 e� �1' &I CENSUS TRACT <br /> Owner's Name . ,(/1,�.,�� Y Phone <br /> Address d '` IO� n City2-.�, <br /> Contractor's Name - - License #l�Thone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / ' PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 77 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 A Cable Tool Dia. of Well Excavation 0 . <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public. PI Driven Gauge of Casing <br /> C Irrigation 1 Gravel Pack Depth 'of Grout Seal �. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical rt Surface Seal Installed By':'- - <br /> PUMP <br /> y':'- -PUMP INSTALLATION: Contractor <br /> Type of Pump to r �' g H.P. 6�.d <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> I / LOU) 1 <br /> PUMP .REPAIR: State Wark Done . , 7'77 CU 0 —ale, � t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -E <br /> Describe Material and Procedure <br /> I hereby agree to comply with,i 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 4 <br /> information is true to the best of. my knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL SSP c` To <br /> SIGNED fif _ ITLE !`� 1 <br /> ()RAW PLOT PLAN ON RIWERSE SIDE) . <br /> 7 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `-f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY / DATE <br /> -- -�, <br /> E H 1426 Rev. 1-74 <br /> 2M <br />