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a <br /> + . C ". )e'44A- SAN JOAQUIN LOCAL ,HEALTH DISTRICT ��- <br /> FOR OF ICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. Y� <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> ` THIS PERMIT ,EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 3 t , _ <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 Joa.quis <br /> County Ordinance No. 1862 and the Rules and Regulations of :the San Joaquin Local Health District. <br /> j JOB ADDRESS/LOCATION a CENSUS TRACT, <br /> Owner's Name �1� mn r / Phone <br /> Address 2 D .SZZ City <br /> Contractor's Name 11 . License # 3_7ajThone -r-74,7,4. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /..../ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION ./ / PUMP REPAIR / / PUMP REPLACEMENT / <br /> 'Other / / <br /> DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY - � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <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 /> "j� Domestic/private Drilled '' Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal G <br /> Cathodic Protection Rotary _ -.Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Il <br /> _ 3 Y <br /> PUMP INSTALLATION: Contractor �� ).o <br /> Type of Pump -' H.P. <br /> " <br /> PUMP REPLACEMENT: /)C/ State Work Done e—,= ( 1, c <br /> PUMP .REPAIR: / / State Work Done !� <br /> DESTRUCTION OF WELL: .Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby 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. on a new well, I will furnish the San Joaquin ,Loca1 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 knowle-d ',and belief. I WILL CALL .FOR A GROUT INSPECTION <br /> ' PRIOR TO GRO TING AND A FINAL IN C N..- <br /> SIGNED. TITLE <br /> bRAW PLOT PLAN ON`REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE 71-71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .-INSPECTION PH44E I/ NAL INSPECTIO <br /> INSPECTION BY- DATE . INSPECTION DATE 2 _2 X7--7 <br /> k_ E H 1426 Rev. , 1-7.4 ` <br /> 6"77 2M <br />