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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOfliOFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. �>�� 7C —� 7i <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .� > <br /> 7�-z1c�P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -S�70 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distinct 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 j*-" (,e0 710 )Ilatza CENSUS TRACT <br /> Owner's Name Phone <br /> Address Q .20- city <br /> Contractor's Name <br /> r.0 License —• Phone <br />�_�PE OF WORK (Check): NEW WELL /7 `DEEPEN /7 RECONDITION /DESTRUCTION <br /> PUMP INSTALLATION,,/ / PUMP REPAIR /? PUMP REPLACEMENT f7 <br /> Other j / <br /> ISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES PIT PRIVY <br />' SEWAGE DX.SPOSAL-FIELD CESSPOOL/SEEPAGE PIT OTHER {� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL -f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I _ Cable Tool Dia. of Well Excavation <br /> t Domestic/'private trilled Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing <br />} t. Irri%atfgn 'Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> t Geophysical ` A$* Surface Seal Installed BY: <br /> f PUMP INSTALLATION: ContractoIrr f <br />' r Type ofPump H.P. <br /> PUMP REPLACEMENT: /% Stag Work Damelg r , <br /> PUMP :REPAIR: l f ` <br /> } / St to Work-Don , <br /> ij SjRUCTION OF WELL: Well Diameter ���' 0 K Approximate Depth <br /> Describe Material and Procedure C'e <br /> 5 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> " + DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BY' '--____.�_ ._...,_...---s. -_— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE)AWFINAL INSPECTION/- <br /> INSPECTION <br /> NSPECT NINSPECTION BY DATE �( - INSPECTION BY DATE <br /> t 77 <br /> E H 1426 Rev. 1-74 1-74 2M <br /> kms✓- <br />