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SAN JOAQUIN LOCAL HEALTH DISTRIU. <br /> L. <br /> FOF�;OFF .CE Ufi : 160]. E. HazeltoiAve. , Stockton, Calif.° , <br /> Telephone: (209) 466 .678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-317 ''" � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) ij <br /> Application is hereby made to` the San Joaquin Local Health District for a permit to cone,truct <br /> and/or install the work 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 /> JOB ADDRESS/LOCATION 41L42,r,4f� o CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address City <br /> Contractor's Name CO. License # SY.2—phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR-/ PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'/pr)-r- PIT PRIVY --- <br /> R36h. sk-0_0­5 SEWAGE DISPOSAL FIELD r~ CESSPOOL/SEEPAGE PIT OTHER { <br /> PROPERTY LINE = PRIVATE DOAiESTIC WELL' PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ . Cable Tool Dia. of Well Excavation .9Y_ II <br /> „ <br /> Domestic/private �X Drilled Dia. of Well Casing 74 <br /> Domestic/public Driven Gauge of Casingr <br /> Irrigation f,� Gravel, Pack Depth of Grout Seal !; <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical s ' Surface Seal Installed 'B : <br /> € ! <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P. i. <br /> PUMP REPLACEMENT: . / / State Work Done i <br /> PUMP REPAIR: / / St Ce ork�l]one <br /> DES-TRUCTION OF WELL: We Iaj S 6 / pproxi ytep <br /> Describe Mate ial and Procedure i <br /> I hereby agree to couiply 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 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.-knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE Al-LR14 , <br /> (DRAW PLOT PLAN ON REVERSE S1DE <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �-c3 <br /> ADDITIONAL COMMENTS: <br /> P INSPECTION PHASE III FINAL INSPECTION ' T <br /> INSPECTION BY 0, DATE . F7 5 INSPECTION BY DATE <br /> E H 1426 Rev.' 1�-71s '-w. �. r' f./7� 0M <br />