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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued gc f7� <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 Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATION Qr,Z2 CENSUS TRACT <br /> D . <br /> Owner's Name �� Phone <br /> Address c2a3,2. Z ,,� RCity 6 <br /> Contractor's Name .(if l License �� 2,Z70 Phone <br />" <br /> TYPE"OF-WORK"("Check) i"NEW-WELL"_ DEEPEN / / 'RECONDITION /-7= DESTRUCTION/777 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Wj2./--SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAZ FIELD ",� " CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial l �—Cable Tool. Dia. of Well Excavation a Poo <br /> _7U�:7�Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout n2 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. / <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> w <br /> DESTRUCTION OF WELL:; Well `biameter Approximate Depth .,J0 <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 b of- my..knowledge and belief. I. WILL CAT, FOR A GROUT INSPECTION <br /> PRIOR TO GRO IN AND A FIN NSP ION. <br /> SIGNED' TITLE <br /> I <br /> DRAiP T' PLAN ON <br /> REVERSE SIDE) <br /> i -• F R DEPARTMENT USE ONLY <br /> PHASE I <br /> F APPLICATION ,ACCEPTED BY, : DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> x INSPECTION BY DATE INSPECTION BY ('. 1 DATE <br /> 3/76 2M <br /> t E 'H .142.6 Rev. 1-74 <br />