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SAN JOAQUIN LOCAL HEALTH DISTRICT C\cS r. r <br /> FOB OFFICE E USE: 1601 E. Hazelton Ave. , Stockton, Calif. — <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q'610- <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z <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 andthethe Rules and Regulations of the San Joaquin Local Health District. <br /> 4-15 <br /> JOB.ADDRESS/LOCATION �/� CENSUS TRACT <br /> 3 Owner's Name <br /> .�de4'w Phone % - <br /> ` Address City " <br /> ' "�Iricense_l�g"L Phone <br /> Contractor s Name �� �/st�'' ;,, <br /> t t <br /> ' TYPE OF.WORK (Check) : NEW WELL DEEPEN / RECONDITION /7 DESTRUCTION /7, <br /> ' PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT-;/ T <br /> Other <br /> YDISTANCE TO NEAREST: SEPTIC TANK ,1A4 SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD 1.20 CESSPOOL/SEEPAGE PI��Q -OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL o%Ll' PUBLIC DOMESTIC-WELL <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 —_ <br /> f Domestic/public Driven Gauge of Casing /fJ <br /> Irrigation DC Gravel Pack Depth of Grout Seal IC-3)�/ _ <br /> Cathodic Protection �f_ Rotary Type of Grout (!f-iY.V 1 <br /> Disposal Other Other Information <br /> Geophysical �A Surface Seal Installed B <br /> ` R <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump— �- H.P. . <br /> PUMP REPLACEMENT: /, / State'Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> x <br /> DESTRUCTION OF WELL: .Well Diameter p`� Approximate Depth <br /> Describe� Materia1 and Procedure <br /> �. I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Land 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 well-and-not-;£y.-them-before-putting-,-the wed,lin-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 GPJUTIPG.MLD JpFIML INSPECTION. <br /> SIGNED fj TITLE . <br /> DRAW PLOT PLAN oN REVERSE SIDE)r_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> , APPLICATION ACCEPTED BY 1 ,N ,VL -- <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTI )N <br /> P SE II GROUT INSPECTION <br /> 4+ DATE 7 7 5 <br /> I.INSPECTION BY DATE (�- y'� 1 ... ,.,. INSPECTION BY C 6� <br /> . . 1177 2M <br /> E H 1426 Rev. 1-74 <br />