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� r <br /> .SCIINAN JOAQLOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7-13-7 <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 and` the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r I SUS TRACT <br /> Own`er's Name Phone <br /> Address City - GkrgA, <br /> Contractor's Name 1 License # v�� ' ,Phone jf� ; j�� <br /> TYPE--OF,­WORK (Check)- NEW-W6L-1, DEEPEN'/? `RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION '/ / PUMP REPAIR -/-7—pump REPLACEMENT'' /77 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 3aa-[+SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGETFTT- � THER <br /> 4. -. PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT. <br /> INTENDED USE TYPE OF WELL. � �+F CONSTRUCTIOM. SPECIFICATIONS:` <br /> -4LIndustrial Cable Too�:� Dia.`'af Well Excavation r- <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public J Driven -GAuge of Casing `3 <br /> Irrigation ,, 4 Gravel Pack Depth. of Grout Seal <br /> --T Cathodic Protectionf- i Rotary Type of Grout <br /> Disposal. '�, '. Other Other Information <br /> Geophysical Surface Seal Installed.B <br /> PUMP INSTALLATION: Contractor; -PGC__Za ^ <br /> T-ype Of_Pump-,_fH.P. <br /> 42 <br /> � .�- `-bawl .�.,- •-�' —�-�� � r r <br /> PUMP REPLACEMENT: State Work Done., . :' 4 <br /> PUMP REPAIR: /_7 '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 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 <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br />'f PHASE 'I } <br /> APPLICATION ACCEPT B DATE <br /> L ' <br /> ADDITIONACOMMENT <br /> PHASE II GROLrr198PECTION V PHAS III/EAL-INSPECTI N <br /> INSPECTION ' DATE INSPECTION BY DATE <br /> l 77 <br /> -2M.2M <br /> E H 1426 Rev. 1-7/, � �- !i� �_ <br />