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- 7� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFPI USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Y Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Is`eued -11--7-7s- <br /> Application <br /> L-7-7s <br /> (Complete In Triplicate) te-7_ 11C-20 <br /> and/orn install <br /> is hereby made to� the San Joaquin Local Health District for a permit to construct <br /> and/oz install the work herein described. This application is made is compliance with San Joaquin <br /> County Ordinance No. 1862 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> ,.2g22& 4c-,. retSrE� q Y <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _�Ok +l <br /> "•� '� , '� '� Phone <br /> Address i S <br /> n City <br /> Contractor's Name U t <br /> � Licence <br /> i Y hone Y G L <br /> t <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 N i <br /> PUMP INSTALLATION /_7.PUMP REPAIR 0 PUMP REPLACEMENT % N j <br /> Other /7 <br /> DISTANCE TONEAREST: SEPTIC TANK S <br /> EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ! <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CO STRUCTZON SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout �I <br /> t Disposal <br /> Geophysical Other Other Information <br /> - Surface Seal Installed Bv• <br /> PUMP INSTALLATION% Contractor � � <br /> Type of Pump `7' H.P. <br /> PUMP kEPLACEMEN1': L7 State Work Done <br /> PUMP :REPAIR: /�c7 State Work Done /".`�.,%y� vv- rp—...-„m — � t <br /> �STR1.CTION OF WELL: Well Diameter Approximate Depth <br /> n Describk Material-and 'Pi•ocedure <br /> I herebyagree <br /> o comply� <br /> 8 •with-A1 '-rats and regul'atione of the San Joaquin Local Health District <br /> and the StAte-of.California:per tainiag,to or r_eg sting well construction. Within FIFTEEN DAYS " <br /> after completion of <br /> mP my work on anew well, I will furnish-the San Joaquin Local Health District a <br /> WELL DRILLERS-aMRT A the;well�nnAwnotifylthem-lbefore"putting the ,well in use. The above <br /> information is [rile Lo the best of my 1 �_ a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO-G UTING.AND�A4FINAL� S I <br /> SIGNS ITLE �r <br /> RAW PIAN ON% E SIDE) <br /> N,FOR rDEPARTMENT USE ONLY <br /> AP" 'CATION'ACCEPTED BY <br /> IDATE �67 <br /> t �ZOnAI, CO2RffiNTS: '.�'r� <br /> PHASE II-GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B7 ATE <br /> E E 1426 Rev. 1-74 i_7t ou <br />