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G� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFiCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .yp 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8 -,W16)_;c4_r (Complete In Triplicate) I <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- compliauce.with San Joaquin <br /> County Ordinance No;: 1862 and the RuZn=z;k!=SUS <br /> Local Health District. <br /> .JOB ADDRESS/LOCATION TRACT <br /> f?raner's <br /> Name $C.IJ Phone,/ ''. 6 <br /> 1;-Address r City <br /> is <br /> Contractor's Name Licensehon �� _ <br /> E <br /> TYPE OF WORK- (Check): NEW WELL -/ DEEPEN -/-7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION . <br /> Other PUMP REPAIR /-7—PUMP REPLACEMENT %f <br /> /J <br /> DISTANCE TO NEAREST; SEPTIC TANK 6 SEWER LINESCcWPIT 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 SPECIFICAT S <br /> Industrial Cable Tool' . Dia. of Well Excavation I cig[t <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 _ ;5 � 73 <br /> Disposal ' Other Other Information <br /> Geophysical -• - -� <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> 3 r 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP+'.REPAIR �. ._. <br /> --- �.. -� - ,.-�/�5 to t�Wo fk Doris <br /> ESTRUCTION OF WELL: 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 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 1 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEf <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE 1 <br /> ADDITIONAL COMMENTS: <br /> LILL- <br /> PHA 11 GROUT INSPECTION ; PHW AIqENAL INSPEC ION <br /> INSPECTION BY DATE - INSPECTION BY DATE s <br /> ^E H 1426 - . Rev. 1--74 <br /> 1-7 A 9M <br />