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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT BXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 1l <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i. JOB ADDRESS/LOCATION �( C//ir Y� 0 �P 1)`M -4-9 CENSUS TRACT <br /> f Ilh .. it <br /> Owner's Name Phonez"' 02 �l <br /> 4 Address I� <br /> �'7'7 City , .i�4"A <br /> Contractor's Name p License hone <br /> l Zl d <br /> TYPE OF WORK (Check) : :NEW WELL DEEPEN a/% RECONDITION / ;DESTRUCTION /_7' <br /> ''PUMP INSTALLATION X/ PUMP REPAIR '/ / PUMP REPLACEMENT /- <br /> .- iOther / / i. <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 f} SEWER LINES , PIT -PRIVY <br /> SEWAGE DISPOSAL FIELD � CESSPOOL./SEEPAGE PIT -�•vr , OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-Y- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private : Drilled Dia.- of Well Casing <br /> Domestic/public - ; . aDriven 4. Gauge-of `Casing`` � -- - �- <br /> Tlrri anon �� -� ,- <br /> 8 �F Gravel Pack � Depth of Grout Seal �j�_�r <br /> Cathodic Protection ��� Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: .Contractor b <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . I� <br /> / / State Work Done .. <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` <br /> Approximate Depth <br /> Describe Material and Procedure i <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 "cons.truction. 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 ofll•the well and notify them before putting the..well in use. The above R <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A "FINAL IN5 ECT ION. { <br /> ',SIGNED TITLE <br /> DRAW Eft' PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY. <br /> PHASE I _...* <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMDATE / %/ <br /> MENTS: i� <br /> PHASE II GROUT INSPECT ON P /F AL INSPECTTO <br /> INSPECTION BY J- . DATE INSPECTION BY DATE ,Z <br /> E H 1426 Rev. 1-74. <br /> 3/76 2m' t <br />