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SAN JOAQUIN LOCAL` HEALTH DISTRICT <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ,,r' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� �U� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> f 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 of the San -Joaquin Local Health District. <br /> I <br /> ' JOB ADDRESS/LOCATION QLL 1AT,E12 FREIV04 'CAjnQ CENSUS TRACT <br />> Owner's Name E DF� Phone <br />_ . 2-- 60 <br /> Address <br /> City AXF/11cti c��,o <br /> Contractor's Name <br /> COLO Z&f License #2447 Phone 7 <br /> 1 <br /> _ i <br /> TYPE OF WORK (Check) : NEW WELL DEEPkN ` <br /> I . - � _/�/i-' RECONI3I'£ION /� DESTRUCTION /7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / " PUMP REPLACEMENT /7 <br /> Y <br /> DISTANCE TO NEAREST: SEPTIC-'TANK _(20 SEWER LINES 60 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD`" - ---CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE'.PRIVATE DOMESTIC.WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable T'o'd"l .: --'-`-'Dia:"of Well Excavation <br /> Ai <br /> -- Domestic/private t , „�rflled� 3 -� Dia. of Well Casing I� �• <br /> Domestic/public i Driven Gauge of Casing 1,7 . <br /> Irrigation 1 C Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout T / E <br /> Disposal I Other <br /> Other Information } <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. f? f <br /> PUMP REPLACEMENT: .� <br /> / / State Work Done <br /> PUMP .REPAIR: <br /> /7/ State Work Done , <br /> i <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth s <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 DA S 1 <br /> after completion of my work ori a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we'll 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 GR ING AND A INAL INS CTION. <br /> SIGNED <br /> 'yTITLE 'T <br /> (DRAW PLOT'PLAN _ON REVERSE SIDE) <br /> ' 1 <br /> PHASE I �FORwDEPARTMENT- USE ONLY a <br /> APPLICATION ACCEPTED,,,BY' � <br /> ADDITIONAL COMMENT_ S ! 77 <br /> P Il GROUT I�NSP TION -C C� 0 <br /> INSPECTION BY ,_ PHASE FIN <br /> AL INSPECTION <br /> aI3AmE - - INSPECTION BY-4,- <br /> DATE <br /> _ <br /> 7 <br /> 11 <br /> A� klell vl•a7� <br /> E H 1426 Rev-. 1-74 i X77 _ 2M h ; <br />