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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70—R.'-'OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21 -920 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is tereby 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 Joaquln ' <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �- CENSUS TRACT <br /> Owner's Name f Phone ✓J <br /> �? G� <br /> Address �?� � <br /> . City <br /> Contractor's Name 7, A s-�`2 <br /> G. 1 d= I�z License #2ZZ4hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/_/ RECONDITION' /-7 DESTRUCTION /-7PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. . <br /> a <br /> PUMP REPLACEMENT: State Work Done ; (, <br /> f IV <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 bistrict <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 G TING AND A KNAL INSPECTION. <br /> SIGNED TITLE � f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) or <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE5��� <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION P%ASEjIII FINAL_-INSPECTI•N <br /> INSPECTION BY ` DATE INSPECTION BY j / DATE 2//11-72 <br /> .V i <br /> E H '1426 Rp.T- 7-7L 1177 2M <br />