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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: b�� <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -�{Jle 4J <br /> ?6-41,?3 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued aZ -a6 <br /> (Complete In Triplicate) <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 compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San JSo''aq��uyyin Local Health District. <br /> JOB ADDRESS/LOCATION I g g <br /> f�a.g� CENSUS TRACT 1 <br /> Owner's Name �� ��,, /(�;_ Phone <br /> Address _�=2 �9 JV "TALLy 2 -- City Z-0 o2l C <br /> L <br /> Contractor's Name � License #QS-ol,0_3 Phone 1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK p/ 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 /> _ Y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1'2- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout Seal D` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information \� <br /> Geophysical Surface Seal Installed By: VV <br /> PUMP INSTALLATION: ContractorAZ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / 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"constructi.on. 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 INSPE TION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED & TITLE <br /> W(DRAWT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .1 5� 46 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT;9N PHASE III/FINAL INSPECTION <br /> INSPECTION BY C,oT, DATE 7 Z I* INSPECTION BY -��— DATE <br /> 3/76 2M V <br /> E H 1426 Rev. 1-74 .. <br />