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SAN JOAQUIN�OCAL,HEALTH DISTRICT <br /> FOE QFFICE USE: 1601 E. Hazelton Ave. ' Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7 1Z 7D <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued a-ll 2r <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local- Health District fora permit to construct <br /> and/or install the work herein described, This application is made in -compliance with San Joaquin. <br /> County Ordinance No. 1.862 andthe Rules and Regulations o£ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION fir _ CENS S TRACT <br /> Owner's Name Phone <br /> Address S2 'ayoon City <br /> A5 � <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN f / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f� <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANKQQ� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL /1"J#-/- CESSPOOL/SEEPAGE PIT OTHER WPW-75 + " <br /> PROPERTY LINE -• PRIVATE DOMESTIC WELL PUBLIC DOMESTIC_WELL — <br /> �., - INTENDED USE TYPE OF WELL - --— CONSTRUCTION SPECIFICATIONS. <br /> Industrial A Cable Tool Dia. of We11 Excavation a <br /> Domestic/private '1 Drilled Dia, of Well Casing r� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 10 <br /> ,Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical € Surface Seal Installed B : _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ;:t H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP" PAIR �""".'-"'" /`Sta-to.'Work Tone '"'•" <br /> D TRUCTION OF WELL: �il ]diameter s .e/-•` a JG%W app xima ep <br /> Describe Material and Procedure.' " , <br /> fI hereby agree to comply with all lawsf;and regulations of the San Joaquin Local Health District- <br /> and the State of California pertaining�`to 'or' regulating well-construction. Within FIFTEEN DAY'S <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WEL"�-DRILLERS REPORT of-the'''well and' notify_them before-putting thewell in use.. . The above r' <br /> in£o.4.mation..is true -to the best of, my knowledge and%ellef. I WILL -CALL FOR A GROUT INSPECTION <br /> li PRIOR TO GR TING AND FVj9 INSPECT ON. . - <br /> SIGNED TITLE <br /> A ( W PLOT-PLAN ON NIIRSE SIDE),) <br /> FOR DEPARTMENT YSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !N DATE-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE TU/FINA TU/FININSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE04 2 0 7 !� <br /> f l <br /> E H 1426 Rev. , 1-74 r. ` �i2 � A� � -_ /2 - 7- . �" r <br />