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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FQF0'rFICE USE: 1601.. E-. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l,/ <br /> (Complete •In Triplicate) 7-V <br /> Application is hereby made to <br /> the San Joaquin Local Health District for aer ' <br /> p , mit 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 Distric y' : ' <br /> JOB ADDRESS/LOCATION N M of L-';.S : .. CENSUS TRACT 2C�S_ 21F0�25 <br />` Owner's Name Phone --2 .5� <br /> I <br /> Address a w - �*. City .SC <br /> Contractor's Name <br /> License �� �� � Phone &W-22d...._ 7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION J J DESTRUCTION /_7 �. <br /> PUMP INSTALLATION X/ PUMP REPAIR !/ PUMP REPLACEMENT J� S <br /> } <br /> -...p `Other* �►�, . 2LC .C. /v Ge- � <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES <br /> PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - 60 <br /> PRIVATE DOMESTIC WELL - _PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .' <br /> Industrial l Cable Tool Dia. of Well Excavat-ion <br /> Domestic/private I, Drilled � . Dia. of Well-Casing <br /> DomestieJpublic Dr-inen.r 'Gauge of Casing 1 <br /> Irrigation Gravel Pack Depth of-Grotit Seal- "`"" <br /> Cathodic%Protee,tiorr i .''`Rataryj6. Type of, Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 3 <br /> PUMP INSTALL:4TION: Contractor <br /> _ <br /> ,4 Type `kot-f�Puim O�� a <br /> _ H.P. <br /> PUMP REPLACEMENT: l J '�N' � <br /> / / State Work Done <br /> PUMP State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health Distract <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 will and notifythem before <br /> 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 FIN NS CTION. <br /> SIGNED .` TITLE <br /> °j . (DRAW PIAT PLAN ON REVERSE SID )!!�: <br /> - <br /> `r FOR DEPARTMENT USE ONLY <br /> PHASE I o pp <br /> APPLICATION ACCEPTED BYr14 f DATE ` <br /> ADDITIONAL COMMENTS: ` 'i <br /> PHASE II G INSPECTION: ys P E /FIN INSPECTION <br /> INSPECTION BY �. �s""�;'DATE �,•. �.' ' ,.� INSPECTION BY DATE � ,m <br /> E H 1426 Rev. - I-74 6/77 2M <br />