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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfx;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> -- 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) �'z7-eo2-p r-1 <br /> Application is Hereby made to the San Joaquin Local health District for a permit to construct <br /> mnd/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 /> -7-& a JOB ADDRESS/LOCATION ALJ S 3e r ,CENSUS TRACT <br /> Owner's Name ` <br /> � Phone ' <br /> Address C-i <br /> City ' <br /> p f A <br /> Contractor's Name `" <br /> f! Lieense._ ct,? Phone <br /> TYPE OF WORky(Check): NEW WELL DEEPEN RECONDITION RECONDITION % f DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other <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 "1 <br /> INTENDED USE TYPE .OF WELL CONSTRUCTION SPECIFICATIONS <br /> dus trial _ W <br /> Cable To'o7. -'�"""-Dia:of WeI1'Excavatiioa�" W <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation - Gravel`.Pack -,-Depth-of-Grout- Seal r <br /> Cathodic,Protection Rotary X _ � � Type, of�lGrout _1 <br /> Disposal Other i Other Information <br /> ��.. X1_2 <br /> Geophysical x -� Surface-Seal Iristalled�'By: a, <br />� PUMP INSTALLATION. ,- Contractor <br /> T L� <br /> e of Pu "�. <br /> Type PUMP H.P. - - <br /> �4 <br /> PUMP REPLACEMENT ` 1,/ / State Work Done~ <br /> PUMP .REPAIR: / / State Work Done <br /> � Y <br />} FJE&TRUCTIO OF_WELI.,_.-e...We11 Diameter ""AFproximafe epW <br /> * _ Describe Material and Procedure <br /> E 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.:knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> IPRIOR TO GROUJJN% AND FINAL INCTI <br /> SIGNED _UETITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I / n <br /> APPLICATION ACCEPTED BY �� W+R DATE/ t K 2/ <br />; ADDITIONAL COMMENTS: UU <br /> PHASE II GROUT INSPECTION PHASE.11,IIVINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 <br /> I E H 1426 Rev: 1-74 - - - h/75 2M- <br />