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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�34K W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 26-75" <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 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 ,„ CENSUS TRACT <br /> Owner's Name Phone <br /> Address 'f` r <br /> y City <br /> Contractor's Name - License # ��d <br /> � •� Phone 97. <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN/_7 RECONDITION / f <br /> DESTRUCTION / <br /> PUMP. INST LATION -/ / PUMP REPAIR/-7—Pump REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> T <br /> AZ <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER --� j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC.WELL-- 11W1% <br /> INTEND PE OF WELL `. , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool /Dia. "af-Well-EXcavation _j <br /> : Domestic/private Drilled Dia. of Well Casing <br /> *,Domestic/public . _- Driven Gauge Gauge of .Casing _.- ± <br /> Trriga`tion. i Grave]. Pack Depth of Grout Seal <br /> —' Cathodic Protection �Rotar <br /> �, Y €— Type of Grout - <br /> Disposal : Other , Other Information ' ' <br /> Geophysical + r Surface Seal Installed By: n <br /> PUMP'INSTALLATIONo; to <br /> f � . <br /> Contracr 1 <br /> Type of 'Pump::..• W� 'r F _- -.. H.P. <br /> ` , <br /> PUMP REPLACEMENT: • ++ <br /> State Work Done <br /> PUNK' 'REFAIR: / / State Wo.rk:�Don� <br /> k e ; <br /> DESUTRUCTION OF*WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hkrfeby 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 oni -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 PI ""INSPECTION. <br /> SIGNED' <br /> TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE). <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .1 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> . DATE <br /> f <br /> PjiA,$EpjI GROUT L_?H4S I FINAL INSPECTION <br /> INSPECTION BY DATE - �S�'� � iNNSPECTION-BY• DATE -157� <br /> E H 1426 Rev. 1-74 `'��`3�`�,"ire- �, � cv ,� 1,'/71� 9M <br />