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"SAN JOAQUIN LOCAL HEALTH DISTRICT ;E <br /> FOE:OFFICE USE: 1601E Hazelton elton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67.81.- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7%2,3 4, <br /> 76 -•97aP <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date �`Issued <br /> (Complete In Triplicate) . . .!I r---•--` <br /> Application is hereby made to the San Joaquin Local health District for a permiVfto construct <br /> and/or install. the work herein described. This application is made in compliance with, San Joaquin <br /> k County Ordinance No.,l. b ed the wand RegulaCiona of the San. Jaaq�Laca1:;,Hea� District. <br /> GLS- <br /> ' JOBLOCATION ENSUS TRACT <br /> Owner's Naas: t Phone <br /> Address �4 City ' <br /> Contractor's Name '� �. �L(/ .� License #,U Phone Zt <br /> TYPE OF WORK (Check): ; NEW WELL DEEP r <br /> /7 RECONDITION /7 DESTRUCTION / <br /> PUMP INS LATION / PUMP REPAIR -/� PUMP REPLACEMENT 'I17 <br /> Other <br /> l�-`" <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES "¢ PIT PRIVY- F r <br /> SEWAGE D I S P4SA& <br /> IELD C SSPOOL/ EEPAGE PIT��/-OTHER <br /> PROPERTY LINERIVATE DOMESTIC WE10&T PUBLIC DOMESTIC�,WELL 1 <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ilv <br /> Domestic/private Drilled Dia. of Well Casing 16 <br /> Domestic/public Driven Gauge of Casing / 2., �, c <br /> Irrigation 0 Gravel Pack Depth of Grout Seal. -` el <br /> Cathodic Protection _ Rotary Type of Grouts�ArL. , <br /> DisposalOther Other Information " <br /> Geophysical Surface Seal Installed B <br /> ? <br /> PUMP' 'INSTALLATION.: lContractor € <br /> Type of Pump , H.P. . <br /> PUMP REPLACEMENT:. / / State Work Done <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 District <br /> and the State of Califbrdia pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of myl�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 tolithe-best af. my,:.knowledge and belief. I- WILL CALL .F R -A ROUT INSPECTION <br /> PRIOR TO GROUTING AND -A FINAL INSPECT .01 <br /> SIGNED dCn��Wfet,��� V .5 <br /> d� (DRAW PLOT PjW ON REVERSE SIDE <br /> �� R DE ARTMENT USE ONLY <br /> PHASE I 's <br /> APPLICATION ACCE D BY ,,XR DATE -74 <br /> ADDITIONAL COMMENTS <br /> PHAR IIG UT INSPECTIO PHAS II F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /l <br /> E H 1426 Rev: 1-Z4 :' -_4/75- 2M <br />