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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FCR OFFICE USE: J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3--)_Z,22� <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. 1862 and the Rules and Regulations f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ,.....�,� <br /> Owner's Name �p-� . Phone <br /> Address 2.� City <br /> Contractor's Name ed4vi cense # 3alzq --I Phone 1030 �7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION f_1 bESTRUCTION /_ <br /> PUMP INSTALLATION / / _PUMP REPAIR / / PUMP'.REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4AjL SEWER LINES PIiT1-PRIVY,;Aj 141 <br /> SEWAGE DISPOSAL FIELD 4p CESSPOOL/SEEPAGE PIT`- OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL # zPbBiIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. nµof Well..Excavation -- <br /> /01 �. <br /> 1.,-Domestic/private 1 [-Drilled Dia, of Well Casing <br /> k. =.Dome,stie/public_- I.- `Drive Gaug€o =Cas -ng %- 7- - �.► , <br /> Irrigation t t/ Gravel Pack Depth of Grout Seal <br /> Cathodic Pro e <br /> t ctio �Rotar <br /> n � Type of Grout <br /> Y YP <br /> Disposal " :: �_ Other Other Information <br /> Geophysical <br /> f� Surface Seal Installed BY: a <br /> 'PUMP INSTALLATION: Contractor j <br /> Type of Pu 1'cv T, H.P. <br /> PUMP REPLACEMENT! / / State Work Done <br /> PUMP .REPAIR: v /-7 State Work Done <br /> T A41_0 oc,rne - <br /> . <br /> DESTRUCTIONOF WELL: . Well ..Diameter. _ Approximate Depth <br /> DES _ <br /> + <br /> Describe Material...a d Procedure ; �1 i <br /> If" <br /> go, <br /> 41- <br /> fl-hereby ag a to comply with al-1 lawsMnd regulatiolfs of the San Joaquin Lo&hl Health Distri011 <br /> ct <br /> and the State of California pertaining to or regulating we11'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 10ell and notify them before 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 TOG G. AND FIN ! SPECTION. <br /> SIGNED TITLE ° <br /> DRAW Ph' ~ ON RE FRSE SIDE ,.. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY 6 <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E II ROU INSPECTI N PHAS TT FINAL INSPECTIO <br /> INSPECTION BY TE INSPECTION BY DATE g- 1-17 <br /> E H 1426Rev. '1-74 //7 / E . ru - 3/76 2m i <br />