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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.!-;--1,4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued--W—A4—ZS. <br /> g (Complete In Triplicate) I77—64;r-1,5- <br /> Application is hereby made to the San Joaquin Local health District for a past to construct ti <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 id CENSUS TRACT <br /> Owner's Name Wd Phone <br /> Address City <br /> Contractor's Name License # j Phone L5--Z2 fZ)31 <br /> Z7 Z�27,M101 <br /> TYPE OF WORK (Check): NEW WELL/1• DEEPEN /-7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other 1 I <br /> DISTANCE TO NEAREST. SEPTIC TANK /47LO! 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �r <br /> Domestic `i <br /> /public Driven Gauge of Casing f�, p <br /> Irrigation Gravel Pack Depth of Grout Seal 5,e9 6 <br /> Cathodic Protection :/ Rotary Type of Grout <br /> Disposal. Other Other Information 76 J �`".� <br /> Geophysical Surface Seal Installed By: -'.1.4 r' f�iv�t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. % _ - <br /> i _ <br /> . PUM , REPLACEMENT: / / State Work Done <br /> PUMP :RE IR: /7 State Work Done <br /> ES•TRUCTION 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 ,regulat.ing 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 TOG UTING AND A FUIAL,fINSP ION. 1 <br /> SIGNED TITLE J 'g <br />` (DRAW OT PLAN ON E SIDE <br /> OR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED DATE 7 '_1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTLON , <br /> INSPECTION BY DATE ', INSPECTION BY DATE <br /> "� E H 1426 Rev. 1-74 1-74 2M <br />