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} SAN JOAQUIN LOc ,HEALTH DISTRICT i <br /> FOF�4OFFICE USE: -1601 E. Hazelton.A4-e- , -Stockton, Calif. <br /> Telephone:�_ ,(209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. . 7 p <br /> THIS PERMIT `EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L=/D_�� <br /> (CompleteIm':Triplicate) <br /> Application is hereby made to the Safi Joaquin :Y.ocal Health.D strict, for a permit to construct <br /> .and/or install the work herein des cribea ,.,Thio application-4s made in compliance with San Joaquit: <br /> County Ordinance No. 1862 and the Rulesand .Reg7lations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION _ < - l t a t{ = ___,:-.CENSUS .TRACT <br /> i Owner's Namey //� Phone <br /> Address v" `" . . ----? e. --- >< - City <br /> Contractor's Name Licensel 7y��home - <br /> 17 <br /> TYPE OF WORK (Check): NEW WELL,L-7 DEEPEN/ I;I RECONDITION /? DESTRUCTION <br /> PUINSTALLATION / / :'pPUMP REPAIR _7 PUMP REPLACEMEN17 <br /> MPT — <br /> h tither / J <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, ISI. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATES-DOMESTIC WELL PUBLIC'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONS'TRUCTION. SPECIFICATIONS v <br /> Industrial Cable Tool i_ Dia. of Well Excavation �! <br /> Domestic/Private Drilled ii Dia. of Well Casing <br /> j Domestic/public Driven ' Gauge of Casing <br /> f�_.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 M <br /> Type :of Pump 777Z__ � �' 4 . H.P. YS_ <br /> ry� v <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '-I.tEPAIR: State Work Done <br /> ZES•TRUCTION OF WELL: Well Diameter . IApproximate Depth <br /> Describe -Material and iProcedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f and the State of California pertaining to or ` cegulating 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 knowled1e nd-b ief. I WILL CALL F'OR A'GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL XNSEECZIO <br /> SIGNED a.c d TLE <br /> j T PLAN ON REV SE SIDE <br /> fi7.,-�Ri!L�DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - �I <br /> " PHASE .II GRO SPECTION P SPECTION <br /> INSPECTION BY DATE ' ' INSPECTION BY _ DATE <br /> t <br /> 1-74 .2M <br /> E H1l+26 Rev. Y-74 <br />