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It } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 L 7Aj <br /> I THIS PERMIT EXPIRES 1 YEAR PROM DATE -ISSUED Date Issued 7-If- <br /> (Complete <br /> lete In, Tri <br /> i� Com <br /> K, ( P plicate) 4 , <br /> Application is hereby 16de to the San Joaquin Local health District for a permit to construct <br /> and/or install the worn 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 /> i!r <br /> JOB ADDRESS/LOCATION t. CENSUS TRACT r <br /> Owner's Name 3: Phone4 <br /> q <br /> Address .Q.� City ,• <br /> . 3 <br /> Contractor's Name i <br /> , License # Phone �--0 <br /> G � <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/7 RECONDITION % j DESTRUCTION 'I T <br />` PUMP INSTALLATION J' PUMP REPAIR PUMP REPLACEMENT <br /> :Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k <br /> SEWAGE DISPOSAL FIELD ----..--CESSI'pOL-/SEEPAGE PIT E OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> i INTENDED USE ��. TYPE OF WELL CONSTRUCTION SPECIFICATIONS . Vs <br /> Industrial Cable :Too1 Dia. of Well Excavation i <br />�. _ Domestic/private Drilled Dia. of Well Casing <br /> { Domestic/public � . Driven Gauge of Casing _ <br /> Irrigation 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection iRotary Type of Grout <br />{ , 'Disposal,�j I� Other �_ Other Information ! <br /> Geo h sical� �` _„ a`t - ._. <br /> P y � - . _ I� ` � Surface Seal installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT': / / State :Work Dion <br /> 1 <br /> PUMP REPAIR:' /� State Work Done 1 <br /> DESTRUCTION OFWELL: Well Diameter Approximate, Depth <br /> eu <br /> Describe Material and Procedure <br /> ,- 5 <br /> .I hereby agree to,comply-with_all--laws-and--regulations-of-the;San'-J'oaquln'Local Health District <br /> And the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion- of my work ansa new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofji;the well and notify them before putting the..weli. in•use-... The above <br /> information is true to the-best-of-my..knowledge and belief_. I.WILL CALL' FORA GROUT INSPECTION <br /> PRIOR TO GROUT G 'AND A i-i'FWh INSPECTION <br /> SIGNEDTITLE <br /> E i DRAW PLOT PLAN ON REVERSE SIDE v <br /> PHASE 'I 'g FOR DEPARTMENT USE ONLY t <br /> AP '� <br /> PLICATION ACCEPTED BYI <br /> DATE ^ <br /> ADDITIONAL, COMMENTS .I. <br /> PHASE II GROUT INSPECTION PHASE 411FIN +INSPECTION <br /> ~II�TSPECTION BY .. �.. ...�-._.DATE:.'7-z -�-7 -- -- YNSPECTION-BY-- ATE <br /> reD t47-6v G�/a nis &C-ri©N• nIo <br /> 1-74E <br /> 'H 1426 Rev. !J5 _ h/75 2M <br />