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co kn, <br /> FOR, SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> O FACE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone:P (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7y <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 axd the Rules and Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 �4- S � <br /> CENSUS TRACT <br /> Owner' s Namer cry a.go u a 5 <br /> Phone <br /> Address _ S Ll/L&✓ <br /> ori g City <br /> Contractor's Name <br /> License # k—Phone v 76?6. <br /> TYPE OF WORK (Check); NEW WELL -/-7 'DEEPEN -/-7 RECONDITION <br />' PUMP INSTALLATION /� DESTRUCTION /? <br /> t <br /> Other l/% /, PUMP REPAIR 2/Pure REPLACEMENT /? <br /> MISTANCE TO NEAREST: SEPTINANK I <br /> f SEWER LYNES PIT PRIVY � <br /> SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE PRIVATE DOMESLTIC WELPUBLIC DOMESTIC WELL <br /> OTHER <br /> INTENDED USE TYPSTRUC <br /> E OF WELL j <br /> Industrial CON :TI SPECIFICATIONS <br /> Domestic <br /> /private <br /> Cable Tool . . Dia. of Well Excavation V <br /> � ' <br /> Domestic/public e '�-- -Dia. o€ We11 `Casing <br /> DrilledDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -Cathodic Protection I Rotary Type of Grout t <br /> �—Disposal <br /> Geophysical uia:. Other Other I €ortion <br /> -� <br /> Surface Seal Installed B : <br /> PUS.' INSTALLATION: Contractor <br /> Type of Pump ` s <br /> < _ H.P. 7/✓ <br /> PUMP REPLACEMENT: 1/ Sate Work Done <br /> PUMP '.REPAIR: <br /> 9 # <br /> /? - State Work Done <br /> E5 TRUGTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth <br /> I hereby agree to comply with {all laws and regulations q¢ the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of � <br /> my work onla new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.. The above <br /> information is true to the—best—of my knowled and belief. t <br /> PRIOR TO GRO TING D A FINAL g I WILL GALL FOR A GROUT INSPECTION <br /> STGNE I ° <br /> TITLE �. <br /> �. RAW PLO PLAN ON ERSE SIDE ---- <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHASE III YNAL INSPECTION <br /> y INSPECTION BY DATE <br /> E H 1 <br /> 426 Rev. 1-74 / <br />