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SAN JflAQUIN LOCA. HEALTH DISTRICT <br /> FOB4O F;CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A-22__,g <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 :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sass Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C/ CENSUS TRACT <br /> Owner's Name .-rQ_ Phone <br /> Address 43_43 11��-ArJ rwp� City <br /> Contractor's NameLicense `Phone2- � <br /> TYPE OF WORK (Check): NEW WELL,'/7 DEEPEN '/7 RECONDITION /'7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -&-7—pump REPLACEMENT 17 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p j <br /> PROPERTY LINE M PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation (� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 47 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion Rotary Type of Grout ' <br /> Disposal Other Other Information x <br /> Geophysical Surface Seal Installed By: <br /> 0 <br /> PUMP INSTALLATION: Contractor G/ <br /> Type of Pump r., /of I.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / State Work Done ' H <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. Wilthin 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 fy�,kn% ed d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING 'AND k <br /> FINAL I P CTI01 <br /> SIGNED ;;5�44g-tW7,•,,_c TLEQx;n?i <br /> P <br /> DRA LOT PLAN ON RE FRSE SIDE <br /> IIr ►, �}/`? <br /> FOR DEPARTMENT USE ONLY <br /> PHAS I �l <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /3 7G <br /> 9/6/7 <br /> - E H, 1426 Rev. 1--74 - - - ��� � /75_-2M <br />