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N <br /> SAN JOAQVIN.IOCAL HEALTH DISTRICT <br /> 0—R,OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-- <br /> -7 <br /> 5=-t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> sand/or instar the work herein deectibed. This application is made in compliance with San Joaquin. <br /> County Ordinance No. 1862 and the Rules and Regulations of-theme San -Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION[/ L�� I .. /.w CENSUS TRACT <br /> Owner's Name P ` 'Phone <br /> Address. _ f City - <br /> -7 <br /> ity . <br /> Contractor's Name c365 License Phone <br /> TYPE OF WORK (Check): NEW WELL -F7 DEEPEN •/ RECONDITION /7 DESTRUCTION / <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 O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />'. Industrial Cable Tool Dia. of Well Excavation <br /> F Domestic/private Drilled Dia. of Well Casing -T <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal "Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump ._ -- - H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP ,REPAIRi-~ /_7 :State Work Done <br /> DE&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describ Material a r cedure <br /> .. <br /> I hereby agree to comply wi- oaf ,the San Joaquin Local He lth District <br /> and the State of -California pertkninfVto or gulating 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 GROUUNG ' A ZIML INSP CTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON. REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE ?,31-� <br /> E H 1426 Rev. 1-74 -- <br />