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4q2� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR('OFFI.0 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> d Telephone: .. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.`7&"--' <br /> 7tl,-» <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 -7� <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 <br /> . and thec Rules and Regulations of the- San -Joaquin Local health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner r s Name .� c Phone (e, ,3 <br /> Address 3 Z' <br /> Contractor s r.Name_. :.Z� - ..w ° ,.=License #/(a 13 z-3 Phone3� <br /> r <br /> TYPE OF WORK (Check): NEW WELL -` DEEPEN /-7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR f PUMP REPLACEMENT 17 <br /> Other / <br /> DISTANCE T9 NEAREST: SEPTIC TANK ---- SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT - OTHER--- ' ' <br /> PROPERTY..,' .INE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _�s_ Cable Tool Dia. of Well Excavation )j +, <br /> Domestic/private Drilled Dia. of Well Casing rr <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation .g Gravel Pack Depth of Grout' Seal ja <br /> Cathodic Protection Rotary - Type of Grout' l e <br /> Disposal } ! Other Other Information <br /> Geophysical . 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> "Type+hof -3 umpIV <br /> _ PUMP-REPLACEMENT: / /- *S tate;.Work Doneju — --- z <br /> PUMP,!REPAIR: State Work-.Done <br /> ES;TRUCTION OF WELL: Well a i me ter ` `� ° Approximat�epth O 1 <br /> 10 Describe Material and Procedure �(�Q <br /> 11 <br /> - - <br /> I ereby gree to cam ly with--all laws and regulations of the San 3oaquin Local Health District <br /> and the State o C iifornia pertaining to,o:r regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; I will furnish the San,l oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notiQAthem before putting tlie..well in-use.. The above <br /> information true to the-best'-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR fi0 GP <br /> .4MING AND NAL INSPECTION. . <br /> SIGNED TITLE , <br /> i ' RAW PLOT PLAN ON REVERSE SIDE <br /> +' OR PARTMENT USE ONLY # <br /> PHASE I <br /> APPLICATION ACCEPTE DATE 4Z 5- <br /> ADDITIONAL COMMENTS: <br /> PYJASF I GROUT INSPECTION P 5-AE II/FINAL INSPECTION <br /> INSPECTION BY DATE -13r� INSPECTION BY DATE <br /> - <br />#1 E H 1426 Rev. 1-74 1-74 2M <br />