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SAN JOAQUIN LOCAL HEALTH:',DISTRICT <br /> Ft -Ok'PICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Dr' D /d" Telephone: (209) ':466:--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No._7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,..`�-22 <br /> t1' (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 a d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /.7 i5r Al CENSUS TRACT <br /> Owner's Name <br /> Phone �8- �3 <br /> Address <br /> Sh City &S401 A <br /> Contractor's Name Q` LicensePhone-��s- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _9s- SEWER LINES ZZ PIT PRIVY <br /> SEWAGE DISPOSAL XIELD _40- CESSPOOL/SEEPAGE PIT j.__ OTHER <br /> PROPERTY LINE &dRIVATE DOMESTIC WELL 30-rPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> � Industrial � Cable Tool Dia, of Well Excavation <br /> ` - Domestic/private Drilled Dia, of Well Casing 6sv <br /> Domestic <br /> /public Driven Gauge of Casing _ _ 1 <br /> Irrigation � V Gravel Pack Depth of Grout Seal , p <br /> �T <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: 2 M. <br /> i <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump H.P. <° " <br /> PUMP REPLACEMENT: State State Wo rk Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ---�- <br /> Describe Material and Procedure r .. <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 orregulating well 'constructi.on. 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 puttingthe- well in use.... The above <br /> information is true to the best of m}� knowledge and belief, I WILL CALL FORvA: GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IVSP TION. I <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REV ERSE'.SIDE)' (A00— <br /> i <br /> c, -.;,.O---��FOR-,°DEPARTMEN.T_USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r s DATE .9 OE <br /> lI <br /> ADDITIONAL COMMENTS: ! <br /> PH:AS. -T GROUT INSPECTION r `_7HAS , 1/Fi AIrINSPECTION <br /> INSPECTION-BY- ATE `�-2' 7 INSPECTION BY _ DATE N-10-7-7 <br /> E H 1426-I t'u' . 1-7L � �� 7'7 _J V2Mi� :� <br />