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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION- FOR WELL 'CONSTRUCTION- OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAW FROM DATE ISSUED Date Issued , -1 7 <br /> j (Complete In Triplicate) <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 /> t <br /> JOB ADDRESS/LOCATION _ _,Z�} C .� �y�e�/Cr CENSUS TRACT <br /> I <br /> Owner's Name Phone 93/ 2/78' <br /> Address �� City c � , <br /> Contractor's Name License V-00739-1 Phone `ii 4T grl�Z y <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN I��I PRECONDITION / / DESTRUCTION /7 <br /> r PUMP INSTALLATION . ;.PUMP REPAIR -A,/ 11-P.UMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Y - <br /> SEWAGE DISPOSAL/FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> vGee_5- PROPERTY LINEJ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Indus trial oi)-` � Cable Tool Dia. of Well Excavation jW`' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public"` Driven Gauge of Casing <br /> Irrigation M Gravel Pack Depth of Grout Seal ,f <br /> F Cathodic Protection ><_ Rotary Type of Grout ,r <br /> Disposal Other Other Information ' <br /> -- <br />', <br /> Geophysical - _ , d ,BY: <br /> P Y Surface Seal Installed <br /> PUMP INSTALLATION: Contractor Ale' , <br /> Type of Pump ell /� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 T <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OFWELL: 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 California pertaining to or regulating well construeion Wi-thin 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 the well and notify them before putting thewell in use. The° above <br /> information is t _e.to thbest f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO R ANDA I FE ON, � _ <br /> SIGNED TITLE <br /> DRAW T" PLAN ON REV RSE SIDE 'i';'1; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P <br /> IN GROUT INSPECTIO PHAS II /FINAL INSPECTIO <br /> INSPECTION B DATE AIINN,�S� --PECTION BY dDATE � ? <br /> J��g 2d 1 <br /> zzT, <br /> 3 76 <br /> E H 1426 Rev. 1-74l-<. .: <br />