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a, ,q p SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 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 <br /> (Complete,-,In Triplicate) <br /> ' Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> j 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 SanJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ Ap o c_✓ J cSt"o CENSUS TRACT <br /> Owner's Name _ a—A- �Y - -�— - Phone <br /> Address ® t—o-c2 G e r"i as City � <br /> Contractor's Name .[] License #/9�-7XJ Phone . -7.4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN 'RECONDITION'RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / 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 N <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 (1` <br /> Cathodic Protection Rotary Type of Grout <br /> k Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Gg' <br /> Type of Pump. - = e H.P. <br /> r <br /> PUMP REPLACEMENT: /% State World Done r <br /> � . <br /> PUMP .REPAIR: - / / State Work Done .D d0 <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 'con.struction. 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(_6knowl ge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO,, 0 TING A FINAL SP N <br /> SIGNED ITLE <br /> PLOT' PLAN ON R SE SIDE) <br /> 0 ARTMEN USE ONLY , <br /> PHASE I / <br /> } APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> + PHASE II GROUT INSPECTION PHAS - III/FI AL INSPECTION <br /> + INSPECTION BY DATE INSPECTION BY DATE Z <br /> r <br /> 3/76 <br /> E H�1426 Rev. 1-74 ., <br />