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iM <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> q FOR70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELT; CONSTRUCTION OR PUMP PERMIT Permit No, 7 SS~GcJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2;- - 7 <br /> II (Complete In Triplicate) 0 1?-3 •- 0140--c P- ' <br /> Application is hereby made to the San Joaquin Local Health District fora 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. i <br /> JOB <br /> z�y_ 1 � <br /> ADDRESS/LOCATION .S s,f� '1 �� _ CENSUS TRACT S <br /> Owner's Name Phone � <br /> II i <br /> Addie®s` � � /ilk? y �`� City � <br />_ -Contractor_s..Name . _ r License jl: �a�Phone f�/, / <br /> TYPE OF WORM (Check) NEW WELLM DEEPEN -/_7RECONDITION /77� � DESTRUCTION f7 <br /> PUMP INSTALLATION Wim}[/ PUMP REPAIR /77 PUMP'._REPLACmiff- f7 NN <br /> DISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSROM/SEEPAGE PIT_,1 &9 %OTHER <br /> iPROPERTY LINE -- PRIVATE DOMESTIC -WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial AV Cable Toole Dia. of.Well Excavation / <br /> yj Domestic/privately T Drilled Y Dia.of Well Casing <br /> Domestic/public{ Driven.. , :. 67k �...-Gadge. of Casing <br /> ,Irrigation ; ' Gravel`-Pack,' Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor o y S <br /> Type of Pump / � ` H.P. <br /> i PUMP REPLACEMENT: I�/ / State Work. Done <br /> PUMP :REPAIR: .Ipf? State Work Done - <br /> pES RUCTION OF WELL: Well Diameter Approximate Depth <br /> QDescribe 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 myjlwork 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 tgj�the•best of my knowledge and belief. I WILL CALL FOR•A•GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED II TLE <br /> P VW PLOT T1W ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I vIl ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: Ili <br /> PHASE II GROUT INSPEC N PHW III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> •y <br /> - 2 H 1426. Rev. 1-7,4 1-74 2M <br />