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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 70E OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ' Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- <br /> /-7 <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 �o r J , tjTy+&e R . CENSUS TRACT <br /> Owner's Name ('e LJO C Q F,f„ Phone $ 3- 1-oQ <br /> Address 3 os' 1Qc Fla aEs 6—r'• City MAA/rF-C Iq <br /> Contractor's Name AQIJL License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ - RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0,o PIT PRIVY <br /> SEWAGE DISPOSAL FIELD P II CESSPOOL/SEEPAGE PIT- OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r C� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> DomestiC/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -- � ` <br /> _ < Irrigation Gravel Pack Depth of Grout Seal "F3 <br /> Cathodic Protection Rotary Type of Grout �aa <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:=gW2 <br /> PUMP INSTALLATION: Contractor C)&j Aj e3_ <br /> Type of Pump, .r. �(a4 P - H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP :REPAIR: / / State Work Done �) <br /> DESTRUCTION OF WELL: Well Diameter , — Approximate Depth <br /> Describe Material and Procedure <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 knowledge and belief. I WILL- CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROWING OD A FINAL INSPECTION. <br /> SIGNED TITLE P44/ov I=— /Z <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P H.ASM I f GROU INSPECTION _ PHASE,.J1X.;/FINA1, INSPECTION <br /> INSPECTION BY DATE /_7 INSPECTION BY E <br /> 2M <br /> E H 1426 Rev. 1-74 / / "� ' �� a77 <br />