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SAN JOAQUIN LOCAL HEALTH. DISTRICT• <br /> FOP OFFICE USE: 1601 E. Hazelton. Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. --448p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /^76 <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 Otdinarice•''No-.' 1862-and the Rules a d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / , O �L.J �S- <br /> CENSUS TRACT <br /> # Owner's Name .. , <br /> �j Phone <br /> Address C>' CP'11 / , ' QZA <br /> city9� <br /> Contractor's NameAq f✓:< License 7- Phox ���6�� <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN _ <br /> _/ / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION I I 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 <br /> Cable Tool Dia o of Well Excavation f <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 <br /> H.P. <br /> r <br /> PUMP REPLACEMENT: '/ State Work � yfti2 <br /> PUMP-"REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Y j <br /> Describe Material and Procedure Approximate Depth <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 'construction. 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 of the. well and notify them before putting the .well 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 /> SIGNED TITLE <br /> DRAW PE T PLAN ON REVERSE SIDE) .— 7; i, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> _ DATE <br /> E H' 1426 Rev. 1-74 3/76 2M <br />