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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FqL OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s z 4r- <br /> TMS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 22=16--7-9- <br /> (Complete <br /> 2-/-i,9- <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 Joaquf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION S_'7S_ CENSUS TRACT <br /> Owner's Nl Phone <br /> Address City <br /> F <br /> Contractall's NameCWioc 54 44 L G. Licensees Phoneme <br /> F EI ! <br /> ,TYPE OF WORK (Check): NEW WELL DEEPEN /� RECONDITION /� DESTRUCTION f7 <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 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Ind$strialable Tool Dia. of Well Excavation "- <br /> Domestic/private Drilled Dia. of Well Casing SXY <br /> Domestic/public -Driven a Gauge of Casing-- <br /> Irrigation Gravel Pack Depth of Grout Seal zva1 <br /> Cathodic Protection L.-�otary Type of Grout <br /> Disposal Other Other Information " <br /> Geo `hysical Surface Seal Installed 'B <br /> PUMP INS TIIALLATIQN: Contractor <br /> Type of Pump H.P . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DE&TRUCTIOIN OF WELL: Wella Diameter Approximate Depth <br /> pth <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 Stiate 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 Local Health District a <br /> ;WELL DRILLERS REPORT of the well and notify them before putting.the..well. in .use.,.. .The above t <br /> information is true to..the-best-of..my.-knowledge and belief. I WILL CALL FOR A 'GROUT ECTION_t,� <br /> PRIOR TOOUTING 'AND A F INSP I0I3. <br /> SIGNED Tkj <br /> ��' DRAW P PLAN . N ERS IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> DATE ZI --18 2 7. <br /> ADDITIONAL' COMMENTS: '- <br /> IPHA E II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTIONf BY DATE /!-/ , INSPECTION BY DATE/a--,S <br /> 1426 Rev. 1--74 h x/75 2M <br /> 6: <br />