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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 r1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.`1_/ ,161,""` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION E CENSUS TRACT ' <br /> 5 <br /> Owner's Name 5Phone -- ° <br /> Address TM I hL fZ&AAA1City SfTQ.C_'IC 7t3/V <br /> Contractor's Name Q C License # 5- Phone <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN / /._RECONDITION �- <br /> PUMP INSTALLATION J J PUMP REPAIR,-/-,/ e PUMP REPLACEMENT � N <br /> Other / / u t — M <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i 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,', L].: , 61.- <br /> Domestic/public. Driven r Gauge of Casing n w C% <br /> i <br /> Irrigation ; Gravel Pack ,-, -Depth of Grout-Seal 5d ge a <br /> ge M <br /> Cathodic Protection _ Rotary d'._. - 7;',A }Type of Grout ► { <br /> Disposal Other ,_•J,.Other Information <br /> Geophysical Surface Seal Installed By: G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ., __ H.P. <br /> PUMP REPLACEMENT: State Work Done I/,� �a <br /> PUMP .REPAIR: / / State Work ;Donee <br /> DES,TRUCTION'OF WELL: Well Diameter. Approximate Depth <br /> Describe Material:.and• Procedure ' <br /> I hereby agree to comply with all 1aws­and-regulations ofr.the San Joaquin Local Health District <br /> and' the State of California pertaining to or regulating-well 'construction. Within FIFTEEN DAIS .� <br /> after completion of my work on a new 'well,,L .will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and :ndtf.fy them before putting the well in use. The above <br /> information i true to the est of myTknowledge and belief. I WILL CALL .FOR A GROUT INSPECTION <br /> PRIOR TO G RO ING ANIA A FYSAL. INSEPVIQN. , w <br /> SIGNED ' 4. _l TITLE <br /> (DRAW`PLOT"PLAN ON REVERSE SIDE) <br /> R D PARTMET USE ONLY <br /> PHASE I`' �,,- <br /> 'APPLICATION ACCEPTED BY J \ DATE / 9 <br />' ADDITIONAL COMMENTS: N -In"... . . <br /> " PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONBY DATE r:1F— INSPECTION BY <br /> .3-.77 71 C��4.,( e—A <br /> El E ;H 1426 Rev. 1-74 s_ �� i f 7 <br />