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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7Z ��- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -JS'-7.7 <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. 186 u 2 and the Rules and Regulations of the San Joaquin Local Health District. + <br /> JOB ADDRESS/LOCATION J (,v �, CENSUS TRACT <br /> Owner's Name , CA <br /> Phone <br /> Address C City JI Uy(D P <br /> Contractor's Name UA-01( WELL (21 <br /> 4.0 P License #7 <br /> (p6 Z Phone <br /> TYPE OF WIRK (Check) : NEW WELL / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INS ZAr I.LATION / / PUMP ..REPAIR PUMP REPLACEME — <br /> �/ NT f <br /> DISTANCE T0 NEAREST: SEPTIC TANK If SEWER LINES 1001 PIT PRIVY f v <br /> SEWAGE DISPO AL FIELD _ DrCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE. -;PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �' '$CONSTRUCTION SPECIFICATIONS <br /> industrial Cade Tool Dia, of Well Excavation ,/d'" <br /> omestic/privateDrilled `" -Di of--WellCasing (P "1 <br /> Domestic/public Driven Gauge of Casing"'. -z- <br /> Irrigation p ; <br /> Gravel Pack Depth of Grout Seal _ 6 <br /> Cathodic Protection Rot—a-r Type of Grout <br /> DisposalOther ~..r. Other Information <br /> ' Geophysical Surf ace Seal' lns'talled By: <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump --,.k ./` +- H.P. --- <br /> PUMP REPLACEMENT: <br /> State Work Done ' , <br /> PUMP .REPAIR: /-/.-State Work Done ;� t <br /> DES-TRUCTION OF WELL: Well Diameter � %Approximate Depth <br /> Describe Material and Procedure <br /> � t <br /> I hereby agree to comply with all laws and regulations of the Sari 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 DRI ERS REPORT of the well and notify them before putting the- well in use.. The above <br /> infor n true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRI T ROU LNIANID A FINAL INSPECTION. ; <br /> S D <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> PHASE I — <br /> � N . FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY�- DATE <br /> ADDITIONAL' COMMENTS: <br /> PHASE II GROUT INSPECTIONP S I FINAL INSPE TION <br /> INSPECTION. BY rj-�� DATE rL.�.� - INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 • � <br /> r X77 <br />