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•!1 !)U) SAN JOAQ�'_TIN qI 5CAL HEALTH DISTRICT e e <br /> FOR OFFICE USE: `G 1601 E. Hazelton Ave. , Stockton, Calif. <br /> li Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L- 7S 76J <br /> Ij _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Lem 6 <br /> ii <br /> (Complete In Triplicate) 2_0 Aga --r3 . <br /> Application is }aereby 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 of the San Joaquin Local Health District. <br /> JOBI ADDRESS/LOCATION aAAA I CENSUS TRACT <br /> OwAer's' Name _� ��!1/.i Phone ...... <br /> 7 <br /> 11; <br /> Address City <br /> Contractor's Name 2�- License # o'1�TQ�13 Phone .?��O'3/ <br /> MA <br /> a <br /> TYPELL <br /> OF WORK {Check) : NEW WE - DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> I PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other 1 / — <br /> j i .. <br /> DISTANCE TO NEAREST: SEPTIC TANK /DDS SEWER LINES PIT PRIVY /J/P,(yrQ� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> i INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS <br /> i� Industrial E Cable Tool Dia. of Well Excavation <br /> -FIZ Domestic/private ! Drilled Dia. of Well Casing pzzo <br /> ,III Domestic/public - Driven Gauge of Casing <br /> Irrigation t, . Gravel Pack Depth of Grout Seal <br /> s <br /> —Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Ij! Geophysical Surface Seal Installed B " <br /> jl <br /> PUMP INSTALLATION: Contractor <br /> ii Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / /. State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 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 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 TO QROUTING AND INAL I X PECT OH.. <br /> SIGNED TITLE <br /> "' DRA :PL T PLAN ON REVERSE SIDE <br /> jl FOR DEPARTMENT USE ONLY <br />�I PHASE I DATE�Q .a.��- �� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:' <br /> PHASE If GROUT INSPECT N PHA III/FINAL AL INSPECTION�7 ;P� <br /> INSPECTION BY DATE ^ O- INSPECTION BY DATE <br /> j j 1 76 2M <br /> E E x 1426 Rev. 1-74 <br />