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SAN JOAQUIN LOCAL HEALTH. DISTRICT L <br /> FOE OFFICE USE: � / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> VVV Telephone: (209) 466-6781 a <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued S-Ia-74 <br /> (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 nd the Rules and Regulations of, the San Joaquin Local. Health 'District. <br /> JOB ADDRESS/LOCATION 'S CENSUS TRACT ' <br /> Owner's Name /� , / L- V � - Phone 000 / J57- � <br /> Address 260-,OL City <br /> �) <br /> Contractor's Name� �"�� / CJ /� License ����3Phod�� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / j DEEPEN / / RECONDITIO / / DESTRUCTION /7 <br /> PUMP 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 Q <br /> Domestic/public Driven Gauge of Casing n <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 /> PUMP REPLACEMENT: / / State Work Done <br /> f."PUMP REPAIR: --State -Work D - / Y`�"'� ' - ``• <br /> � DES•TRUCTION OF WELL: Well Diameter d 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 /> k 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 'Joa4ufn Local Health .Di.strict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the Gill 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 GROUTING AND A FINAL INSPECTION. <br /> rSIGNED „ �..Y TITLE <br /> • 9 r ^ F !. <br /> .CRAW 'Pig T' PLAN 'ON REVERSE�S IDS) <br /> FOR DEPARTMENT USE ONLY <br /> "PHASE I <br /> APPLICATION ACCEPTED BY DATE y <br /> + ADDITIONAL COMMENTS: <br /> PHASE II GROUT IITSPtCTION PRASA I I/F NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 376 2M <br /> E H 1426 <br /> .t ; <br />