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SAN JOAQUIN I CAL HEALTH DISTRICT - 67 •-- <br /> FOFFICE USE: 1601 E. HazeltorAve. , Stockton, Calif. <br /> Telephone:'. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Y4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-y-76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Ordinance No, 1.862 and the Rules an Regulatiotg of the San Joaquin Local Health District. <br /> 2r941-� L-)UA��D <br /> JOB ADDRESS/LOCATION , <br /> 1. /7 . . , , _ CENSUS TRACT <br /> . Ownerts Name 77 <br /> Phone <br /> Address <br /> City - <br /> Contractor's <br /> ity .Contractor's Name4 <br /> r 6 License #7GD_Z Phone 5e,? S� j <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEL$F <br /> RECONDITION /�T DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION 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 Cable Tool Dia. of Well Excavation . <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 Protecr_ ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,,Type of Pump H.P. <br /> PUMP REPLACEMENT /-7 ;State Work Done <br /> PUMP �REPAIR: /7 State Work Done <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 />'DELL DRILLERS REPORT of the well and notify them before putting.the..well. in use... The above <br /> formation is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO O TI G, AN .,A FINAL INSPECTION. <br /> -uED TITLE �. <br /> DRAW PLOT <br /> PLAN ON REVERSE SIDE <br /> 7 FOR DEPARTMENT USE 0 <br />,,,PLICATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: ""— <br /> PHASE II GROUT TSSPECTION PHASE III FINAL INSPECTION <br /> [NSPECTION BY DATE INSPECTION BY DATE <br /> �E H 14 6 , Rev. 1-74 / f;� 9M <br />