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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: (��b° 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - Z 7 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 j <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct E <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 /> JOB ADDRESS/LOCATION CENSUS TRACT ' f <br /> Owner's Name r Phone 3 cj k <br /> Address Q � ���� City (y <br /> Contractor's Name -r License 4tl_�237 Phone3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN '/_`/ RECONDITION /� DESTRUCTION /-J <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other 1 <br /> DISTANCE TO- NEAREST-:---SEPTIC TANK-� SEWER LINES .-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation a <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 /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: )�V State Work Done P.P,�.� 6C <br /> PUMP .REPAIR: Tao- /%-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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-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 AN A RINAL INS CTION. <br /> SIGNED TITLE <br /> W-PLOT T PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY if DATE ,� L <br /> ADDITIONAL COMMENTS: 171 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,dT DATE / 77 <br /> E H 1426 Rev. 1--74 <br /> 3/76 2M <br />