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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: ��601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. .2j; - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> 17 <br /> JOB ADDRESS/LOCATION / r .12AENSUS TRACT <br /> Owner's Name Phone <br /> Address 4V do^- gyp. City /�• �,. <br /> Contractor's Name License # / �Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION _/-;2Z—PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 /> �y 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 /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /X/ State Work Done kCI,16�9 6�� .Im �. <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' # <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above � t <br /> information is true to the-best of my. knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G 0TING AND A FINAL INSP CT 0 <br /> SIGNED �} ITLE d!' , <br /> PLIDT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED `BY DATE /�7 '-/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /D -/-f'?, <br /> 'E H ,1426 Rev. 1-74 ' <br /> 3/76 2 ; <br />