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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO-,!jFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> •' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS 7� <br /> // (Complete In Triplicate) — 2,50-11 <br /> Application is hereby made to the San Joaquin Local Health District"- -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 'S n J .aqu. Local Health District. <br /> _g <br /> JOB ADDRESS/LOCATION 4 r k Vex Ai CENSUS TRACT <br /> k <br /> /60 _ <br /> Owner's Name M. if JA Vietyds, Phone <br /> Address o City 1•r1r.f �i7`" <br /> Contractor's Nam j License it / ,3hone ' -7 9 Z-bl { <br /> i <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C <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 <br /> Domestic/public Driven Gauge of Casing <br /> x 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 /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump C_.b 6W C, oe H.P. I'll—PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /7`/. . State Work Done _v I1 <br /> DESTRUCTION 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 INS CTIO�. <br /> SIGNE - TITLE f� ..ti' <br /> I . . PflT`PLAN ON XWERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I � w � --- <br /> APPLICATION ACCEPTED BY DATE ����� <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT N TI N PHASE III/FINAL INSPECTION ' <br />- INSPECTION BY DATE ' INSPECTION BY DATE <br /> J <br /> 3/75 <br /> E H 1426 Rev. 1-74 ' <br />