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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'4'OFFICE USE: 1601 E. Hazelton Ave. , ' Stockton, Calif. <br /> Telephone: ., (209)` 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3o2a4l <br /> THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued 7-3/1� <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 Joaquini, <br /> County Ordinance No. 1862 'and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> f. `�- �K CENSUS TRACT <br /> 'Owner's Blame h Phone A4 <br /> r-2 qa 1 <br /> Address - a C City c n 6. <br /> Contractor's NamehA cl License #Phone ;.4 <br /> TYPE OF WORK (Check)t NEW WELL„ W DEEPEN/7 RECONDITION /7 DESTRUCTION L7 <br /> PUMP INSTALLATION L`7 PUMP REPAIR _7 PUMP REPLACEMENT 0 <br /> 0 Cher /? r ` <br /> DISTANCE TO NEAREST: SEPTIC TANK &,% SEWER 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation MOR-771 <br /> -- �C Domestic/private Drilled Dia. of Well Casing to <br /> Domestic/public Driver: Gauge of Casing M <br /> Irrigation Gravel Pack Depth of Grout Seal !&a _ <br /> Cathodic Protection .� Rotary Type of Grout <br /> Disposal Other Other Information + <br /> Geophysical k Surface Seal Installed Bot lria e_ <br /> PUMP INSTALLATION-. Contractor <br /> Type of Pump g&t <br /> j,,7.-X) H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP _REPA,IR: L7 State Work Done. f <br /> ES�CTIAN 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 pertainingto 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 know �ldandb lq ief, ` I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG UTINGANDA I ;INSPECTION. C; y <br /> SIGNED TITLE <br /> RAW,PIET PLAN ON REVERSE SIDE <br /> - --7R DEPARTMENT USE ONLY a <br /> PHASE I DATE 7-3 r 3 - I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE I IN INSPECTION <br /> INSPECTION BY DATLO I SPPCTION BY OATV <br /> E H 1426 Rev. 1-74 1-74 2M <br />